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in  2010  with  funding  from 

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INJURIES    AND    DISEASES 


OF 


THE    JAWS 


BY  THE   SAME  AUTHOR. 


A  Course  of  Operative  Surgery.    With  20  Plates  drawn  from 

Nature,  by  M.  Leveille,  Coloured.     Second  Edition,  large  8vo,  SOa. 

Practical  Anatomy  :  A  Manual  of  Dissections,    With  24  Coloured 
Plates  and  269  Wood  Engravings.     Fifth  Edition,  8vo,  15s. 

A  Manual  of  Minor  Surgery  and  Bandaging,  for  the  Use  of 

Hoiise-Surgeons,  Dressers,  and  Junior  Practitioners.    With  129  Engravings. 
Seventh  Edition.     8vo,  6s. 

The  Student's  Guide  to  Surgical  Diagnosis.    Second  Edition. 

8vo,  6s.  6d. 


-> 


.^r. 


,>v 


^^^" 


INJURIES   AND    DISEASES 


OF 


THE    JAWS: 

THE  JACKSONIAN    PRIZE    ESSAY  OF  THE   ROYAL   COLLEGE   OF 
SURGEONS  OF  ENGLAND,   1867. 


BY 

CHRISTOPHEE    HEATH,   E.E.C.S, 

HOLME   PEOFESSOE    OF   CLINICAL   SUEGEBT   IN   UNIVEESITY   COLLEGE,   LONDON,   AND    SUHGEOW 

TO    UNITEESITT    COLLEGE   HOSPITAL  ; 

CONSULTING   SUEGEON   TO   THE   DENTAL   HOSPITAL. 


THIRD    EDITION. 


PHILADELPHIA: 
P.     BLAKISTON,    SON     &    CO, 

1012,  WALNUT   STREET. 

1884. 


H-sr  ■ 


PREFACE 

TO 

THE    THIRD    EDITION. 


In  the  twelve  years  which  have  elapsed  since  the  publica- 
tion of  the  second  edition  of  this  book,  I  have  been  able  to 
add  considerably  to  my  personal  experience  of  the  subjects 
included  within  it.  ,  This  has  led  in  some  instances  to  a 
modification  of  the  views  previously  expressed^  and  espe- 
cially with  regard  to  the  pathology  and  treatment  of  multi- 
locular  cysts  of  the  lower  jaw.  In  connection  with  this 
subject,  I  have  particularly  to  mention  the  microscopic 
investigations  of  Mr.  Frederick  Eve,  to  whose  labours  I  am 
much  indebted ;  and  also  to  thank  Mr.  Eushton  Parker,  of 
Liverpool,  for  his  assistance  in  classifying  the  tumours  of  the 
jaw  according  to  modern  pathological  research.  A  chapter 
on  the  Diseases  of  the  Temporo-maxillary  Articulation  has 
been  added.  To  the  successive  Surgical  Eegistrars  of 
University  College  Hospital,  Messrs.  Beck,  Godlee,  Gould, 
Pepper,  Burton,  Silcock,  Boyd  and  Horsley,  my  very  best 
thanks  are  given  for  the  careful  records  of  my  hospital 
cases,  and  the  microscopic  examination  of  numerous  speci- 
mens of  disease. 


Cheistophee  Heath. 


36,  Cavendish  Square, 
February,  1884. 


PREFACE 

TO 

THE    FIEST    EDITION. 


"  The  Injuries  and  Diseases  of  the  Jaws,  including  those  of 
the  Antrum,  with  the  treatment  by  operation  or  otherwise," 
having  been  announced  as  the  subject  for  the  Jacksonian 
Prize  of  1867,  I  prepared  an  essay  upon  the  subject,  to 
which  I  had  for  some  years  devoted  considerable  attention ; 
and  having  been  successful,  I  have  printed  it  with  but 
slight  alterations.  My  very  best  thanks  are  due  to  those 
gentlemen  who,  by  generously  placing  valuable  preparations  of 
disease  at  my  disposal,  enabled  me  to  study  the  pathology  of 
the  subject  more  successfully  than  I  could  otherwise  have 
done^  and  also  to  those  who  have  kindly  given  me  notes  of 
interesting  cases  under  their  charge,  or  have  lent  me  valu- 
able illustrations,  of  which  due  acknowledgment  has  been 
made  in  each  instance.  I  venture  to  hope  that  the  infor- 
mation thus  brought  together  may  be  of  service  to  those 
under  whose  care  similar  cases  may  be  placed. 

Christopher  Heath. 

September,  1868. 


TABLE    OF    CONTENTS. 


CHAP.  PAGES 

I.   FEACTUKE   OF   THE   LOWER  JAW 1 —   14 

II,   COMPLICATIONS   OF   FKACTURE   OF   LOWER  JAW    .      .      .  15 —   32 

III.   TREATMENT   OF   FRACTURED   LOWER  JAW 33 —   55 

IV.   FRACTURES   OF   THE   UPPER   JAW 56 —   65 

V.    GUNSHOT   INJURIES   OF   THE   JAWS   .     1 Q6 —  82 

VI.   DISLOCATION   OF   THE  JAW 83 —   97 

VII.   INFLAMMATION,  ABSCESS,  PERIOSTITIS 98 — 109 

Vni.   NECROSIS   OF   THE   JAWS 110 — 126 

IX.   REPAIR  AFTER  NECROSIS  ;    TREATMENT 127 — 141 

X.   HYPEROSTOSIS 142 — 151 

XI.   DISEASES   OF   THE    ANTRUM 152—^177 

XII.    CYSTS   OF   TEETH;   DENTIGEROUS   CYSTS 178 — 195 

XIII.  CYSTS     OF    LOWER    JAW    AND     MULTILOCULAR     CYSTIC 

TUMOUR 196 — 213 

XIV.  TUMOURS   CONNECTED   WITH  TEETH   AND   ODONTOMATA  214 — 226 
XV.   DISEASES   OF   THE    GUMS — EPULIS 227 — 247 

XVI.   TUMOURS   OF   THE   PALATE 248 — 253 

XVn.  EPITHELIOMA   OF   THE    GUMS   AND   ANTRU3I    ....  254 — 259 

XVni.   NON-MALIGNANT   TUMOURS    OF   THE  UPPER   JAW      .      .  260 — 286 

XIX.   SARCOMATOUS                 „                       „                        „          .      .  287 — 301 

XX.  MALIGNANT                      „                       ,,                        ,,          .      .  302 — 313 

XXI.  DIAGNOSIS    AND    TREATMENT     OF     TUMOURS     OF     THE 

UPPER  JAW 314 — 326 

XXII.   NON-MALIGNANT   TUMOURS   OF   THE   LOWER   JAW     .      .  327 — 343 

XXin.   SARCOMATOUS                „                      „                       „         .      .  34i — 368 

XXrV.  MALIGNANT                   „                    „                     „        .     .  369 — 378 
XXV.   DIAGNOSIS     AND     TREATMENT     OF     TUMOURS     OF     THE 

LOWER  JAW 379—387 

XXVI.    CLOSURE   OF   THE  JAWS 388 — 411 

XXVII.   DISEASES  OF  THE  TEMPORO-MAXILLARY  ARTICULATION  412 — 427 

XXVIII.   DEFORMITIES   OF   THE   JAWS 428 — 433 


APPENDIX   OF    CASES 434 — 472 


ILLUSTRATIONS 


Fig. 


1.  Fracture  with  over-lapping 

2.  ,,         with  displacement 

3.  „  of  condyles  and  coronoid  process 
4  Fracture  united  at  an  angle,  from  St.  George's 


Hospital  Museum  . 


(Hepburn) 


after  Malgaigne 

Fergusson 

Original 


7.  Displacement  with  fibrous  union 


8.  Fibrous  union,  from  University  College  Museum       Original 


9.  Ununited  fracture  after  gunshot  injury 
10. 

11.  Four-tailed  bandage  for  lower  jaw 

12.  Gutta-percha  splint    . 
13. 

14.  Hamilton's  apparatus 

15.  Hammond's  wire  splint 
M.  »  .       „ 
17.  Thomas's  wire-suture 
18. 

19.  Wheelhouse's  method 

20.  Hayward's  mouth-piece 

21.  Gunning's  interdental  splint 
22. 
23. 
24. 

25.  Bean's  apparatus 

26.  Lonsdale's  apparatus 

27.  „  „  modified 

28.  Moon's  splint 

29.  „  ... 

30.  Fracture  of  upper  jaw 

31.  Plate  for  ditto     . 
Sla.Gunshot  fracture  of  upper  jaw 
31&. 

32.  Gunshot  injury  of  face 

33.  Ununited  gunshot  fracture 

34.  „  „ 

35.  Gunshot  injury  of  face 

36.  „  of  jaw 

37.  Silver  chin 

38.  Dissection  after  loss  of  jaw 

39.  Dislocation  of  jaw 

40.  _„      _        „    _  .         . 

41.  Dissection  of  dislocation  of  jaw 

42.  Dislocation  of  jaw 

43.  „  old 
**.            i>  >)         •        • 


after  Malgaigne 


Cox  Smith 

Original 
Erichsen 

after  Hamilton 
Original 
•  jj 

Erichsen 


B.  Hill 


after  Hamilton 
B.  Hill 

33 

Bryant 

•  33 

Salter 

33 

.    Cox  Smith 

'  33 

jDehout 
.    Cox  Smith 

33 

Dehout 


Astley  Cooper 

after  Malgaigne 

Original 

.    Fergusson 

B.  W.  Smith 

.    J.  Coicper 


9 

10 
12 

21 
21 
21 

24 

29 

31 

31 

33 

34 

34 

35 

36 

37 

39 

40 

41 

43 

44 

45 

46 

47 

48 

61 

52 

52 

52 

57 

57 

71 

71 

73 

78 

78 

79 

79 

80 

80 

85 

86 

87 

88 

89 

91 


ILLUSTRATIONS. 


Fia. 

45.  Stromeyer's  forceps    . 

46.  Necrosis  of  the  alveolus 

47.  „  „  „  .         . 

48.  Necrosis  of  intermaxillary  bones 

49.  Necrosis  of  lower  jaw 

60.  „        of  upper  jaw 

61.  Portrait  of  patient 

62.  Repair  after  phosphorus-necrosis 

53.  „ 

54.  Hyperostosis,  portrait 

55.  „  „  .         .  _ 
„                   ,,       after  operation 


56. 
57. 
58. 
59, 
60. 
61. 
62. 
63. 
64. 
65. 


„  „       cast  of  palate 

,,  „       section  of  jaw 

Antrum  Highmorianum 


with  vertical  septum 
subdivided  (with  jjerfo ration) 


,,  „  of  normal  size 

,,  ,,  of  large  size 

,,  ,,  of  very  small 

Antra  of  unequal  sizes 

66.  Antrum  prolonged  into  malar  bone 

67.  .  ■-  ■    - 
68. 
69. 
70. 

71.  „       ....         . 

72.  Distension  of  antrum 
73. 

74.  Cyst  of  antrum  (W.  Adams) 
75. 
n.  Cyst  of  teeth      . 

77.  ■„ 

78.  „  „  .        . 

79.  Cyst  of  lower  jaw 

80.  „ 

81.  „ 

82.  Inverted  tooth     . 

83.  Dentigerous  cyst  (Feam) 
84. 
85. 

86.  ,,  ,,        (Underwood) 

87.  Calcified  cyst  (Cartwright) 

88.  Patient  with  dentigerous  cyst 

89.  Dentigerous  cyst 

90.  Skeleton  of  cyst  of  lower  jaw  (St.  Bartholomew 

91.  Multilocular  cyst  of  lower  jaw 

92.  ,,         .       ,,  „ 

93.  Large  cystic  sarcoma  of  lower  jaw  (Author) 

94.  Patient  three  months  after  .  ,, 

95.  Cystic  sarcoma  of  lower  jaw  (Hutton) 

96.  Cast  of  multilocular  cysts  .... 

97.  Multilocular  cystic  tumour 

98.  Recurrent  cpitheUoma        .... 


after  Goffres 
Nicholson 

Bryant 
Tay 
Hart 

>» 

Savory 


after  HoicsJiip 
Fergusson 


Original 


Cattlm 


Fergusson 

Original 

after  Giraldes 

Original 


Fergusson 


Tomes 

Original 

>> 

Forget 

Original 

Cattlin 

Original 

Forget 

Original 

E.  Adams 

Cusach 

Original 

»f 

R.  Adams 

Original 


95 
111 
111 
114 
116 
118 
118 
129 
129 
143 
147 
147 
149 
150 
150 
152 
152 
153 
154 
155 
155 
156 
156 
157 
157 
158 
158 
162 
170 
172 
173 
178 
178 
178 
183 
184 
184 
186 
188 
188 
189 
190 
190 
192 
194 
198 
200 
201 
203 
203 
204 
208 
209 
210 


ILLUSTRATIONS. 


XI 


Fig. 

PAGE 

99.  Misplaced  tooth        .... 

Forget 

215 

100.            „          „            .... 

)> 

215 

101.  Odontoma  (Fergusson) 

Tomes 

218 

102.           „ 

Forget 

219 

103.           „          (Author) 

Original 

222 

104           „                 „                  ... 

)) 

222 

105.          „ 

Salter 

224 

106.          „         .         .        .         . 

5) 

224 

107.           „ 

Forget 

224 

108.          „ 

Tomes 

225 

109.  Hypertrophy  of  gum  (MacGillivray) 

Original 

229 

110.             „                   „            (Author)      . 

„ 

230 

111. 

•         "                ?j 

230 

112.  Hypertrophy  of  alveolus      ,, 

)j 

231 

113.  Papillary  tumour  of  gum  (Fergusson) 

Salter 

234 

114.          „             „        of  palate       _    (Cock) 

„ 

235 

115.          „             „                „       section     ,, 

)) 

235 

116.  Epulis  (Hutchinson)     _    . 

Original 

235 

117.        „      myeloid  (Hutchinson)   . 

j> 

236 

118.        „      giant-celled  (Wilkes)     . 

„ 

237 

119.        „      (AiTthor)        .... 

>j 

238 

120.        „            „ 

•                )> 

241 

121.        „      case  of  Mary  (Griffiths  . 

Listen 

242 

}> 

243 

123.  Cross-cutting  forceps 

,, 

245 

124.        „                „           .        .        .        . 

)) 

245 

125.  Bone-forceps 

Fergusson 

246 

126.        „        „          ..... 

'                )) 

246 

127.  Tumour  of  hard  palate  (Author)     . 

Original 

250 

128.  Epithelioma  of  gum 

.  .     Fergusson 

255 

129.  Fibrous  tumours  of  upper  jaw. 

Liston 

262 

130.   Ann  Struther  before  operation 

!) 

263 

131.      ,,          „        after  operation  . 

,, 

263 

132.  Mrs.  Frazer 

IJ 

264 

133.  Large  recurrent  enchondroma  (Author)  . 

Original 

270 

134.  Osseous  tumour  (Dupuytren) 

after  F.  de  Cassis 

278 

135.        „            „                „      .         .         .         . 

•                )? 

278 

136.        „            „         (Fergusson)    . 

Original 

281 

137.        „            „        (Duka)             .         .       I 

atliological  Society 

284 

138.  Myeloid  of  upper  jaw       .         .         .         . 

Canton 

293 

139.  Medullary  sarcoma  (Craven)    . 

Original 

303 

140.        „                  „ 

»j 

305 

141.  Double  medullary  sarcoma          (Author) 

5> 

306 

142.  Medullary  sarcoma  of  both  jaws        „ 

307 

143,  Epithelioma  of  antrum                        „ 

» 

311 

144.  Gensoul's  incision     .         .         .         .         . 

Fergusson 

316 

145.  Lizars'        ,, 

'                >> 

317 

146.        „             „ 

•                                    99 

317 

147.  Scar  of  face 

318 

148.  Incisions  on  face 

Liston 

319 

149.  Saw 

Fergusson 

320 

150.  Lion  forceps     ...... 

9) 

320 

151.  Fibroiis  tumour  of  lower  jaw  (University 

College)   Original 

327 

152.        „             „              ,,.... 

Spencer  Wells 

328 

Xll 


ILLUSTRATIONS. 


Fig. 

153. 

154 

155. 

156. 

157. 

158. 

159. 

160. 

161. 

162. 

163. 

164. 

165. 

166. 

167. 

168. 

169. 

170. 

171. 

172. 

173. 

174. 

175. 

176. 

177. 

178. 

179. 

180. 

181. 

182. 

183. 

184. 

185. 

186. 

187. 

188. 

189. 

190. 

191. 

192. 

193. 

194. 

19.5. 

196. 

197. 

198. 

199. 

200. 

201. 

202. 

203. 

204. 


Fibrous  tumour  of  lower  jaw  .         .        .        Spencer  Wells 
Fibrous  tumour  between  plates  (King's  College)      Orighial 
Large  fibrous  tumour  (Fergusson)  .         .  ,, 

Upper  jaw  of  ditto  ......  ,, 

Recurrent  enchondroma  of  lower  jaw 


Ivory  exostosis  of  lower  jaw  (South) 
„  „  ,,  (Author) 

Large  osteo-sarcoma  of  lower  jaw   . 

Patient,  after  its  removal  .... 

Large  osteo-sarcoma  of  lower  jaw  (Author)     . 
„  ,,  after  removal 

Recurrent  fibroid  of  lower  jaw 

Myeloid  tumour  of  symjohysis  (Craven) 

„  ,,  ,,  section  of    „ 

Myeloid  tumour  of  lower  jaw  . 

„  ,,      of  both  sides  of  jaw  (Author) . 

Patient  after  operation 

Chondro-sarcoma  of  lower  jaw  (Author) 

Ossifying  sai'coma  ,, 

Girl,  after  removal  of  cancer  of  lower  jaw   ,. 

Epithelioma  of  chin  ,, 

Epithelioma  of  gland  attached  to  jaw      ,,     ' 

Gag  for  mouth  (Hutchinson)    .... 

Incision  for  removal  of  lower  jaw    . 

Tumour  of  centre  of  lower  jaw 

Incision  for  removal  of  lower  jaw    . 

Cast  of  misplaced  wisdom-tooth 

Closure  of  jaws  by  cicatrices  (Author)     . 

Effects  of  Esmarch's  operation 

Closure  of  jaws  and  cicatrix  of  cheek  (Author) 

Effects  of  operations        ..... 

Closiire  of  jaws  by  cicati'ices   .... 

Shields  for  application  to  gums  (Clendon) 

Patient  to  whom  these  had  been  fitted  (Holt)  . 

Diseased  temporo-maxillar}^  joint    . 

Rheumatoid  arthritis  of  coudj'les    . 


Law  son 
Original 

Sytne 

?) 
Original 

j> 

LawBon 


Fergusson 
Original 


Fergusson 


Weiss 
Original 


Weiss 
Original 


„  ,.  glenoid  cavity  .  „ 

Hypertrophy  of  neck  and  condyle  (McCarthy)  „ 

Patient  with  hypertrophy  of  neck  (Author)    .  „ 

Treatment  of  temporo-maxillary  arthritis  (Goodwillie) 

„  fibrous  ankylosis  „ 

Oral  speculum  „ 

Spiral  spring  ,, 

Deformity  of  maxilla  from  cicatrix  of  burn    .  Tomes 

Deformity  of  jaws  from  cancrum  oris      .         .         Harrison 
Same  patient  after  operation  ....  „ 

„  ,,        after  second  operation       .         .  „ 


PAGE 

329 
329 
331 
332 
338 
339 
341 
342 
347 
347 
349 
350 
354 
355 
358 
358 
360 
361 
361 
363 
365 
370 
375 
378 
381 
383 
385 
385 
388 
401 
401 
402 
402 
406 
407 
407 
413 
416 
416 
416 
417 
418 
419 
420 
422 
423 
424 
424 
430 
431 
432 
433 


THE 


INJURIES  AND  DISEASES  OF  THE 
JAWS. 


CHAPTEE  I. 

FRACTURE      OF      THE      LOWER      JAW. 

Fracture  of  the  lower  jaw  is  usually  the  result  of  direct 
violence,  though  Professor  Pancoast  met  with  a  case  in 
which  fracture  of  the  neck  of  the  bone  had  resulted  from  a 
violent  fit  of  coughing,  in  an  old  man  upwards  of  seventy 
years  of  age.  (Gross's  "  Surgery,"  p.  964.)  Blows  received 
on  the  jaw  in  fighting  or  a  kick  from  a  horse  are  the  most 
common  causes  of  the  accident;  but  falls  from  a  height 
iipon  the  face  also  produce  some  of  its  most  serious  forms, 
owing  to  the  comminution  resulting.  The  unskilful  appli- 
cation of  the  dentist's  "  key"  has  been  known  to  cause  a 
complete  fracture  of  the  bone,  but  more  frequently  in  former 
years  than  at  the  present  time,  when  that  instrument  has 
been  almost  entirely  superseded  by  the  forceps. 

Fractures  of  the  alveolus  are  frequently  unavoidable 
during  the  extraction  of  the  molar  teeth,  even  in  the  most 
skilful  hands,  since  the  position  assumed  by  the  fangs  is 
occasionally  such  that  extraction  without  displacement  of 
the  bone  to  some  extent  is  impossible.  These  cases 
ordinarily  give,  however,  little  inconvenience,  since  the 
removal  of  the  alveolus  only  hastens  the  absorption  which 
must  necessarily  ensue  upon  the  removal  of  the  teeth, 
unless  indeed  the  fracture  should  be  so  extensive  as  to  affect 
the  alveoli  of  the  neighbouring  teeth,  in  which  case  exfolia- 

B 


2  FRACTURE   OF   THE    LOWER  JAW. 

tiou  of  a  troublesome  character  may  be  produced.  Unavoid- 
able accidents  of  this  kind  have  on  several  occasions  been 
made  the  ground  for  legal  proceedings  against  the  operator ; 
but  most  unfairly  so,  since  the  exercise  of  the  greatest  skill 
and  care  cannot  on  all  occasions  prevent  mishaps  due  to  the 
natural  conformation  of  the  parts. 

On  this  subject,  which  is  of  considerable  interest  to  those 
practising  dental  surgery,  I  may  quote  a  passage  from  a 
paper  in  the  "  Dental  Cosmos,"  by  Dr.  J.  Eichardsou, 
illustrating  the  difficulty  which  may  be  met  with.  He 
says : — 

"  I  have  never  come  to  regard  extracting  teeth  as  an 
operation  free  from  liability  to  grave  complications.  I  seize 
hold  of  a  tooth  to-day  with  more  misgiving,  with  more 
caution,  than  I  did  the  first  year  of  my  practice.  Eleven 
years'  exj)erience  may  be  supposed  to  have .  given  me  some 
confidence  and  expertness  in  this  operation,  yet  with  each 
year's  added  experience  the  operation  grows  in  importance, 
and  dictates  greater  vigilance  and  prudence.  1  feel  my 
way  through  the  operation  with  more  and  more  caution, 
guard  every  movement  with  greater  circumspection,  and 
magnify  my  skill  more  and  more  with  every  success. 
Through  eleven  years  my  experience  has  been  free  from 
serious  accident,  but  the  catastrophe  came  at  last  when  T 
had  no  possible  reason  to  expect  it. 

"  Within  the  past  two  months  I  fractured  the  inferior 
jaw  severely  in  attempting  to  remove  the  anterior  right 
inferior  molar.  It  was  in  this  way.  The  patient  was  a  lady 
about  twenty-five  years  of  age.  The  crown  of  tlie  tooth 
was  much  decayed,  but  I  had  a  firm  hold  upon  the  neck. 
Alternate  lateral  traction  was  made  upon  the  tooth,  mode- 
rately at  first,  but  increasing  at  every  movement  of  the 
forceps.  There  seemed  to  be  complete  immobility  of  tlie 
tooth  until  the  instant  of  its  giving  way,  which  it  did  with 
the  outward  movement  of  the  forceps.  I  comprehended  in- 
stantly, from  the  enlargement  of  the  gum  below  the  processes, 
that  a  fracture  of  the  maxilla  had  occurred.  On  examination 
I  found  the  detached  portion  adhering  firmly  to  the  fangs 


POSITION   OF   FRACTURE.  S 

of  the  tootli,  and  extending  antero-posteriorly  about  an 
inch  and  a  quarter,  and  in  depth  about  three  fourths  of  an 
inch  or  more.  I  made  no  further  attempts  to  remove 
either  the  tooth  or  fragment  of  bone,  but  pressed  them 
firmly  back  to  their  places,  and  directed  the  patient  to  keep 
the  mouth  persistently  closed.  I  hoped  for  a  reunion  of  the 
fractured  parts." — British  Journal  of  Dented  Science,  August, 
1863. 

Mr,  James  Salter,  in  his  valuable  work  on  "  Dental 
Pathology  and  Surgery"  (1874)  devotes  a  chapter  to  "  The 
casualties  which  may  arise  in  the  operations  of  tooth- 
extraction,"  in  which  he  mentions  that,  in  extracting  an 
incisor  tooth  from  the  upper  jaw,  the  whole  mass  of  bone 
corresponding  to  the  intermaxillary  bones  broke  away, 
and  was  merely  held  in  place  by  the  soft  tissues. 
Fortunately  the  bone  reunited  without  an  untoward 
symptom.  Mr.  Salter  also  refers  to  a  case  in  which  a  most 
able  operator  broke  the  horizontal  ramus  of  the  lower  jaw 
completely  through,  in  extracting  a  tooth  with  the  forceps. 

Gunshot  injuries  of  the  face  may  produce  the  most  ter- 
rible injuries  of  the  lower  jaw,  by  splintering  and  removing 
large  portions  of  it ;  and  the  mere  explosion  of  gunpowder 
in  its  immediate  neighbourhood^  as  when  a  pistol  is  fired 
into  the  mouth  by  a  would-be  suicide,  will  produce  a  fracture 
of  the  bone.      (See  chapter  on  "  Gunshot  Injuries.") 

Fractures  of  the  lower  jaw  are  remarkable  from  the  fact 
that  they  are  almost  always  cooiipound  towards  the  mouth, 
though  the  skin  is  rarely  involved  except  in  gunshot  injuries. 
The  fibrous  tissue  of  the  gum  being  very  inelastic,  tears 
readily  when  the  bone  is  broken  across,  and  thus  the  saliva 
and  the  air  come  in  contact  with  the  fractured  surfaces. 
This  statement  only  applies,  however,  to  fractures  of  the  body 
of  the  bone,  for  when  the  ramus,  or  still  more  when  the 
coronoid  process  or  condyle  is  broken,  the  bone  is  too  deeply 
seated  for  the  injury  to  extend  into  the  mouth. 

Fracture  may  occur  at  various  points  in  the  lower  jaw, 
and  the  body  of  the  bone  is  the  portion  most  frequently 
injured  (in  40  out  of  43  cases  recorded  by  Hamilton) ;  the 

B  2 


4  FHACTURE    OF   THE    LOWER   JAW. 

ramus  from  its  position  and  coverings  being  much  less  liable 
to  injury  except  from  extreme  violence,  such  as  the  passage 
of  a  wheel  over  the  face  or  a  gunshot  injury.  The  coronoid 
process  is  occasionally  broken  off  obliquely,  and  the  neck  of 
the  jaw  has  been  repeatedly  broken  on  one  or  both  sides  of 
the  bone  in  cases  subjected  to  great  violence. 

In  the  body  of  the  jaw  the  fracture  appears  to  occur  most 
frequently  in  the  neighbourhood  of  the  canine  tooth,  this 
position  being  determined  probably  by  the  greater  depth  of 
its  socket,  and  the  consequent  weakness  of  the  bone  at  that 
point ;  but  the  fracture  may  happen  at  any  other  point,  and 
has  been  known  to  occur  exactly  at  the  symphysis  in  cases 
too  old  to  admit  of  separation  of  the  two  portions  of  the 
bone.  Of  the  forty  cases  of  fracture  of  the  body  recorded 
by  Hamilton,  four  were  perpendicularly  through  the  sympliy- 
siS;  and  eighteen  of  the  remainder  were  known  to  be  oblique, 
whilst  of  the  whole  number  no  less  than  thirteen  were 
examples  of  double  and  triple  fractures.  In  twenty  ex- 
amples of  fracture  through  the  body,  not  including  fracture 
of  the  symphysis,  the  line  of  fracture  was  fourteen  times  at 
or  very  near  the  mental  foramen  ;  twice  between  the  first 
and  second  incisor;  three  times  behind  the  last  molar;  and 
once  between  the  last  two  molars. 

The  line  of  fracture,  except  at  the  symphysis,  is  usually 
oblique,  and,  according  to  Malgaigne,  the  thickness  of  the 
bone  is  also  divided  obliquely,  so  that  generally  the  fracture 
is  at  the  expense  of  the  outer  plate  of  the  anterior  fragment 
and  the  inner  plate  of  the  posterior  fragment,  though  this 
rule  is  not  without  exception. 

It  is  impossible  to  gather  any  reliable  details  respecting 
the  position  of  recent  fractures  of  the  lower  jaw  occurring 
in  the  London  hospitals  ;  and  as  this  fracture  is  rarely  a 
fatal  accident  ^?n'  se,  the  hospital  museums  contain  com- 
paratively few  specimens.  An  examination  of  those,  how- 
ever, yields  the  following  results  : — 

The  College  of  Surgeons  possesses  no  specimen  of  recent 
fracture  of  the  lower  jaw,  and  only  a  doubtful  one  of  united 
fracture  near  the  angle  (880). 


MUSEUM    SPECIMENS    OF  FRACTURE.  5 

St  Bartholomews  ITosjntal  possesses  one  specimen  of  frac- 
ture of  the  lower  jaM^  (i.  897),"  showing  a  fracture  on  the  right 
side,  which  extends  obliquely  through  the  bone  between  the 
canine  and  bicuspid  teeth  and  passes  through  the  mental 
foramen." 

St.  Thomas's  Hospital  has  one  recent  and  moist  specimen 
(27) — '^A  comminuted  fracture  of  the  lower  jaw.  The 
bone  is  fractured  near  the  symphysis  and  near  to  both 
angles,  so  as  to  expose  the  nascent  pulps  of  the  last  molar 
teeth.      The  inferior  maxillary  nerves  are  not  lacerated." 

Guys  Hospital  has  only  one  specimen  (1091,'") — "A 
lower  jaw  having  a  doubtful  fracture  (united)  on  the  left 
side  at  the  angle." 

King's  College  Musetim  is  very  rich  in  recent  fractures, 
having  no  fewer  than  four. 

1.  A  fracture  between  the  incisor  teeth,  running  obliquely 
to  the  left  at  the  expense  of  the  external  plate  of  the  left 
segment.  The  right  coronoid  process  is  broken  off  obliquely 
downwards  from  the  sigmoid  notch,  and  the  necks  of  both 
condyles  are  fractured  obliquely.  This  is  the  preparation 
figured  by  Sir  William  Fergusson  in  his  "  Practical  Surgery," 
p.  521,  and  was  taken  by  him  from  a  patient  who  f,ell  from 
a  great  height,  and  received  fatal  injuries.      (Fig.  3.) 

[This  preparation  corresponds  very  closely  to  that  described 
by  M.  Houzelot,  where,  in  consequence  of  a  fall  from  a  height, 
there  were  produced  fractures  of  the  symphysis,  of  both 
condyles,  and  of  hoth  coronoid  processes.  (Malgaigne,  p. 
323.)] 

2.  Is  an  example  of  double  fracture  of  the  body  of  the 
jaw.  On  the  right  side  the  fracture  runs  between  the  lateral 
incisor  and  the  canine  tooth  obliquely  backwards,  at  the 
expense  of  the  external  plate  of  the  posterior  fragment.  On 
the  left  side  the  fracture  extends  from  the  posterior  socket 
of  the  third  molar  tooth  (which  was  broken  at  the  time, 
leaving  the  anterior  fang  in  situ),  obliquely  backwards,  at 
the  expense  of  the  outer  plate  of  the  anterior  fragment. 

This  was  from  a  man  who  was  struck  on  the  jaw  with  the 
fist,  and  died  of  dcliriuni  tremens  in  King's  College  Hospital 


6  FRACTURE  OF   THE    LOWER    JAW. 

in  1857,  whilst  the  author  was  Sir  William  Fergussou's  house- 
surgeon. 

3.  Is  an  example  of  double  fracture  of  the  body,  and  of 
fracture  of  both  condyles.  On  the  right  side  there  is,  in 
front  of  the  last  molar  tooth,  a  fracture  running  obliquely 
forwards  and  then  backwards,  thus  >,  the  upper  division 
being  at  the  expense  of  the  outer  plate  of  the  posterior  frag- 
ment^ and  the  lower  at  the  expense  of  the  outer  plate  of  the 
anterior  fragment.  On  the  left  side  a  very  oblique  fracture 
runs  forward  from  the  front  of  the  second  molar  tooth, 
which  is  broken.  A  part  of  the  external  plate  has  been 
broken  off  and  is  wanting.  The  necks  of  both  condyles  are 
broken  obliquely  downwards  and  inwards. 

The  preparation  is  from  a  woman  who  threw  herself  out 
of  window  and  fell  forty  feet. 

4,  Is  an  example  of  comminuted  fracture-  at  and  to  the 
right  side  of  the  symphysis.  The  left  half  of  the  bone  is 
cut  nearly  vertically  through  the  socket  of  the  left  lateral 
incisor.  The  right  half  is  cut  very  obliquely  from  the 
canine  tooth  at  the  expense  of  the  inner  plate,  and  the 
fragments  would  complete  the  missing  portion  of  alveolus. 

University  College  Museum  is  also  very  rich  in  injuries  of 
the  jaw,  having  four  specimens  of  recent  fractures ;  one  of 
bony  union;  and  one  of  fibrous  union.  All  the  recent 
specimens  show  a  fracture  in  the  neighbourhood  of  the 
symphysis,  which  no  doubt  influenced  Mr.  Erichsen  in  the 
opinion  he  has  expressed  as  to  the  usual  position  of  fracture  : 
"  I  have  seen  fractures  most  frequently  in  the  body  of  the 
bone  near  the  symphysis,  extending  between  the  lateral 
incisors,  or  between  those  teeth  and  the  canine.  The 
symphysis  itself  is  not  so  commonly  fractured,  the  bone 
being  thick  in  this  situation.  The  angle  is  frequently  broken, 
but  tlie  neck  and  coronoid  process  rarely  give  way."  ("  Science 
and  Art  of  Surgery,"  p.  264.) 

1.  Is  a  vertical  fracture  through  the  symjDhysis,  with  a 
horizontal  fracture  running  through  the  alveolus  on  the  right 
side,  separating  the  portion  containing  the  right  lateral 
incisor,  canine,  and  lirst  bicuspid  teeth. 


MUSELTM    SPECIMENS    OF    FFvACTURE.  7 

2.  Shows  a  fracture  running  at  first  vertically,  and  then 
slightly  obliquely  to  the  left  through  the  socket  of  the  left 
lateral  incisor.  The  neck  of  the  left  condyle  is  broken  off 
obliquely  and  very  low  down,  so  that  the  fissure  runs  down- 
wards and  backwards  in  a  line  with  the  posterior  border  of 
the  coronoid  process. 

3.  Is  a  vertical  fracture  through  the  symphysis,  with  a 
portion  of  dried  integument  adhering.  Both  condyles  are 
broken  off  obliquely. 

4.  Is  a  remarkable  example  of  multiple  and  comminuted 
fracture.  One  fracture  runs  obliquely  forwards  in  front  of 
the  left  first  molar  tooth  into  the  mental  foramen.  A 
second  fracture  runs  vertically  between  the  right  incisor 
teeth.  A  third  fracture  runs  very  obliquely  from  the  last 
molar  on  the  right  side  down  to  the  lower  border  of  the  bone, 
opposite  the  canine  tooth.  This  is  met  by  a  fourth  fracture 
running  obliquely  backwards  in  front  of  the  first  molar  tooth 
of  the  same  side.  The  lower  border  of  the  bone  in  the 
mental  region  is  broken  off  and  comminuted  into  numerous 
fragments,  one  of  which  contains  the  mental  foramen  of  the 
right  side.     The  left  condyle  is  also  broken  off  obliquely. 

5.  Is  an  example  of  united  fracture  of  the  jaw  in  the 
right  molar  region,  with  loss  of  all  the  teeth  on  the  right 
side  except  the  last  molar.  The  fracture  was  apparently 
oblique,  and  is  somewhat  irregularly  united  by  bone,  with 
the  result  of  contracting  the  alveolar  arch,  so  that  the  left 
lower  teeth  have  been  thrown  inside  those  of  the  upper  jaw  ; 
and  both  having  been  exposed  to  extra  attrition,  owing  to 
the  absence  of  teeth  on  the  opposite  side,  are  much  worn 
away,  the  lower  on  their  outer  and  the  upper  on  their  inner 
surfaces. 

6.  Is  a  wet  preparation,  showing  fibrous  union  of  the 
jaw  beyond  the  right  canine  tooth,  a  great  part  of  the  body 
of  the  bone  in  that  situation  being  wanting.  Hence  it  was 
probably  a  case  of  comminuted  fracture,  with  exfoliation  of 
a  portion  of  bone.      (Fig.  8.) 

>S'^.  Georges  Hospital  Museum  contains  one  remarkable 
specimen  of  united  fracture  of  the  lower  jaw  (i.  38).     The 


8  FKACTURE   OF  THF>   LOWER   JAW. 

fracture  lias  taken  place  to  the  right  of  the  symphysis,  and 
there  has  been  a  loss  of  substance,  from  comminution  pro- 
bably, so  that  the  two  halves  of  the  body  of  the  bone  meet 
at  an  acute  angle,  all  the  teeth  of  the  right  side  in  front  of 
the  bicuspid  being  wanting.  There  are  small  outgrowths  of 
bone  both  in  front  and  behind  in  the  neighbourhood  of  the 
fracture,  which  is  irregularly  united,  leaviiig  a  hole  in  the 
middle  of  the  union  like  the  socket  of  a  tooth.  The  right 
mental  foramen  is  much  smaller  than  the  left,  the  line  of 
fracture  being  apparently  close  in  front  of  it.  The  sigmoid 
notches  of  this  jaw  are  unusually  large.     (Fig.  4.) 

In  the  catalogue  of  St.  George's  Museum  is  an  account  of 
a  lower  jaw  fractured  through  the  base  of  the  coronoid 
process  and  through  the  neck  of  the  condyle,  in  which  the 
lower  fragment  had  been  displaced  into  the  meatus  auditorius 
externuS;  separating  the  cartilaginous  from  the  osseous  por- 
tion for  nearly  half  its  circumference.  The  preparation 
has,  however,  unfortunately  disappeared. 

The  Lundon  Hosjntal  Museum  contains  one  specimen  of 
recent  fracture  of  the  lower  jaw.  A  fracture  extends 
obliquely  backwards  between  the  second  and  third  molar 
teeth  to  the  left  side,  the  external  and  internal  plates  of  the 
bone  being  equally  involved.  There  is  also  an  oblique 
(downwards  and  backwards)  fracture  of  the  neck  of  the  rii/hi 
condyle. 

The  Museums  of  Westminster,  Middlesex,  Charing  Cross, 
and  St.  Mary's  Hospitals  contain  no  specimens  of  fractured 
lower  jaw. 

St/mptoiiis. — These  are  ordinarily  well  marked.  Since  even 
in  simple  vertical  fracture  of  the  symphysis  the  patient  will 
be  conscious  of  pain  and  slight  crepitus  on  pressing  the 
jaws  together,  and  the  surgeon  will  readily  perceive  the 
irregularity  of  the  teeth  due  to  alteration  in  the  level  of 
tlie  fragments.  The  position  of  a  jjatient  with  fracture  of 
the  jaw  is  very  characteristic,  since  he  endeavours  to  support 
and  steady  the  fragments  with  his  hands  in  the  most  careful 
manner,  and  his  anxiety  for  relief  is  often  most  ludicrously 
complicated  by  his   inability  to  exjjlain  by  word  of  mouth 


OVER-HIDING   OF   FRAGMENTS.  \f 

what  liis  ailment  is.  Where  the  laceration  of  the  gum  has 
permitted  displacement  of  the  fragments,  manipulation  on  tlie 
part  of  the  surgeon  is  unnecessary  for  the  establishment  of 
the  diagnosis  ;  but  when  any  doubt  exists  he  should  grasp 
the  jaw  on  each  side  with  the  forefingers  introduced  into 
the  mouth,  and  will  have  no  difficulty  in  perceiving  the 
movement  and  crepitus  between  the  fragments. 

When  a  single  fracture  occurs  on  one  side  of  the  median 
line,  the  smaller  fragment  is  liable  to  displacement  by  mus- 
cular action,  being  drawn  outwards  and  at  the  same  time  a 
little  forwards,  so  as  to  overlap  the  larger  fragment.  This 
is  due  to  the  action  of  the  temporal  and  masseter  muscles, 
but  principally  to  the  latter,  and  is  favoured  by  the  generally 
oblique   direction  of  the   line  of   fracture  and    consequent 

Fig.  1. 


tendency  of  the  bones  to  override,  as  pointed  out  by 
Malgaigne.  (Fig.  1.)  This  is  well  seen  in  the  fracture  of  the 
left  side  in  specimen  3  of  the  Bang's  College  collection,  and 
during  life  the  deformity  was  well  marked.  Mr.  Lawson 
was  good  enough  to  show  me  a  case  recently  in  which  union 
of  a  similar  fracture  had  taken  place,  and  in  which,  notwith- 
standing every  care,  very  considerable  permanent  displace- 
ment of  the  fragment  had  occurred.  An  instance  of  the 
obliquity  of  the  fragment  being  reversed  is  given  by 
Dr.  Kinloch  in  the  American  Journal  of  Medical  Sciences  for 
July,  1859.  Here  the  patient,  who  was  fifty  years  of  age, 
met  with  a  compound  fracture  of  the  right  side  of  the  jaw, 
in  front  of  the  masseter  muscle.    "  The  line  of  fractiu'e  divided 


10  FRACTURE    OF   THE    LOWER   JAAV. 

the  bone  obliquely  tlirougli  its  thickness,  the  obliquity  being 
at  the  expense  of  the  external  plate  of  the  small  posterior 
fragment,  and  of  the  internal  plate  of  the  large  or  anterior 
fragment.  The  displacement  was  singular  and  marked. 
The  small  fragment  projected  inwards  and  slightly  upwards 
into  the  cavity  of  the  mouth.  The  large  fragment  rode  the 
small  one,  having  retreated  downwards  and  backwards,  and 
its  extremity,  which  was  somewhat  pointed,  could  be  felt 
externally  under  the  integument." 

In  double  fractures  of  the  body  of  the  jaw,  one  being  on 
each  side  of  the  median  line,  the  displacement  is  necessarily 
greater,  since  tlie  muscles  attached  to  the  chin  tend  to  draw 
the  central  loose  piece  downwards  and  backwards  towards 
the  hyoid  bone,  whilst  both  lateral  portions  are  drawn  for- 
wards and  outwards,  as  described  in  the  previous  paragraplis. 
When,  as  is  probably  the  case  in  most  instances  of  the 
kind,  the  obliquity  of  the  fracture  is  the  same  on  the  two 
sides — i.e.,  at  the  expense  of  the  outer  surface  of  both  ex- 
tremities of  the  central  fragment,  no  difhculty  is  experienced 
in  reducing  the  fracture,  and  it  is  only  necessary  to  see  that 
the  posterior  fragments  are  sufficiently  approximated  to  the 

Fig.  2. 


central  portion  ;  but  when,  as  in  specimen  2  of  King's  College, 
the  obliquity  is  different  on  tlie  two  sides,  the  fracture  being 
at  the  expense  of  the  outer  plate  of  the  posterior  fragment 
on  the  right  side,  and  the  reverse  on  the  left  side  (consequent 
no  doubt  ujjon  the  blow  having  been  struck  to  the  left  of  the 
median  line),  it  is  obvious  that  great  difticulties  will  be  en- 


DOUBLE   FRACTURE   OF  THE   JAW.  11 

J. 

■  countered  both  in  reducing  and  maintaining  the  apposition 

of  the  fragments,  as  indeed  was  the  case  with  the  patient  in 
question. 

Malgaigne  records  an  ahnost  similar  case  in  which  reduc- 
tion could  not  he  effected.  "  The  middle  fragment,  which 
was  strongly  drawn  downward  and  backward,  was  easily 
brought  forward  nearly  to  a  level  with  the  other  two,  Ijut 
when  it  came  close  to  that  on  the  riglit  side  it  seemed  to 
catch  against  its  posterior  surface,  as  is  seen  in  the  figure 
(fig.  2),  and  no  effort  could  disenga.ge  it.  On  post-mortem 
examination  the  right  fragment  in  its  upper  half  was  bevelled 
at  the  expense  of  the  external  surface,  the  middle  one  at  the 
corresponding  part  at  the  expense  of  its  internal  face.  This 
bevelled  edge  opposed  an  almost  insurmountable  obstacle  to 
its  disengagement;  there  was  an  overlapping  of  the  edges 
of  which  one  would  have  no  idea.  And  even  after  death  we 
found  that,  to  effect  the  reduction,  it  was  necessary  to  carry 
the  middle  portion  downward  and  forward,  so  as  to  carry  it 
first  below  and  then  in  front  of  the  other." 

An  extraordinary  example  of  double  fracture  of  the  jaw 
was  brought  before  the  Edinburgh  Medico-Chirurgical 
Society  on  the  20th  of  November,  1861,  by  Dr.  Struthers, 
being  from  a  man,  a^t.  19,  who  in  Australia  was  caught  by 
the  coulter  of  his  plough,  when  a  great  part  of  his  jaw  was 
broken  oft'  and  torn  away.  The  specimen  embraced  the 
entire  body  of  the  bone  and  more  than  half  of  the  right 
ramus,  which  had  been  fractured  obliquely  backwards  and 
downwards  from  the  root  of  the  coronoid  process  to  the 
middle  of  the  posterior  edge.  On  the  left  side  the  fracture 
extended  obliquely  across  the  angle,  from  behind  the  socket 
of  the  second  molar  tooth  to  just  in  front  of  the  angle. 
The  patient  recovered.  {EdinhLrgh  Medical  Journal, 
December  1861.) 

Fracture  of  the  ramus  is  usually  produced  by  some  crush- 
ing force,  such  as  the  wheel  of  a  carriage,  as  in  a  case 
recently  under  my  care,  and  the  bruising  of  the  soft  parts 
is  therefore  considerable.  But  little  displacement  ordinarily 
occurs,  owing   to   the  deep  situation   of  the  bone,  and  the 


12  FRACTURE  OF   THE    LOWER  JAW. 

K 

fact  that  it  is  well  supported  on  each  side  by  the  masseter 
and  internal  pterygoid  muscles.  In  the  case  alluded  to 
under  my  own  care,  the  patient  was  a  boy  of  twelve,  and  the 
prominent  symptom  was  the  projection  of  the  lower  incisors 
beyond  the  upper  jaw,  with  slight  displacement  towards  the 
injured  side.  But  when  there  is  much  laceration  and  loss 
of  substance,  as  in  gunshot  injuries,  the  upper  fragment 
is  apt  to  be  tilted  forward  by  the  temporal  muscle,  as  was 
noticed  in  a  case  under  my  own  care,  which  will  be  found 
in  the  Appendix  (Case  III.).  Pain  is  referred  to  the  part, 
and  on  passing  the  finger  well  back  into  the  fauces,  irre- 
gularity and  crepitus  may  be  detected  when  the  patient 
moves  the  jaw. 

Fracture  of  the  neck  of  the  condyle  is  not  so  rare  an 
accident  as  has  been  stated  by  some  authors,  judging  from 
the  number  of  museum  specimens  of  the  accident  which  exist. 
Fig.  3,  from  Sir  William  Fergusson's  "  Practical  Surgery," 
shows  very  well  the  ordinary  appearance  of  the  fracture, 
though  in  some  specimens  the  line  of  fracture  is  more  obliquely 

Fig.  3. 


placed.  This  is  Mell  seen  in  specimen  3  in  University  College 
Museum,  where  the  left  condyle  is  broken  off  so  obliquely 
and  so  low  down  that  the  line  of  fracture  runs  downwards 
and  backwards  from  the  middle  of  the  sigmoid  notch.  The 
cause  in  all  the  recorded  cases  is  the  same — viz.,  a  fall  from 
a  considerable  height.  The  s}'mptoms  are  obscure,  theie 
being  pain  and  difficulty  of  movement  on  the  affected  side, 
and   cre2>itus   perceived  by  the   patient.      The   condyle  is 


FHACTURE  OF    THE    NECK.  13 

drawn  inwards  and  forwards  by  the  pterygoideus  externus, 
as  can  be  ascertained  by  passing  the  finger  into  the  mouth, 
and  the  jaw-bone  is  apt  to  become  slightly  displaced,  so  that 
the  chin  is  turned  towards  the  affected  side  and  not  from  it, 
as  is  the  case  in  dislocation. 

Dr.  Fountain  has  recorded  in  the  New  York  Medical 
Journal,  January,  1860,  a  case  of  fracture  of  the  neck  of 
the  left  condyle  with  fracture  through  the  body  on  both  sides, 
caused  by  a  fall  from  a  height,  in  which  the  following 
symptoms  were  present.  The  jaw  was  displaced  backwards 
and  laterally  on  the  left  side — a  displacement  which  was 
temporarily  rectified  as  long  as  traction  was  made  at  the 
symphysis,  which  the  connexions  of  the  middle  fragment 
with  the  membranous  and  muscular  tissues  permitted.  As 
soon  as  this  traction  was  removed  the  lateral  deformity  was 
reproduced,  and  every  contrivance  resorted  to  failed  to  main- 
tain a  permanent  reduction  of  the  fracture  of  the  neck, 
until  the  upper  and  lower  teeth  were  wired  together  so  as 
to  keep  up  traction  on  the  lower  jaw.  The  case  did  well, 
and  recovered  without  any  deformity. 

When  double  fracture  of  the  neck  occurs,  the  violence 
miist  have  been  so  great  as  in  most  cases  to  lead  shortly 
to  fatal  results,  but  M.  Berard  has  recorded  a  case  in  which 
the  double  fracture  did  not  at  first  lead  to  any  displacement, 
but  on  the  fifth  day  convulsions  ensued,  which  led  to  con- 
siderable displacement  and  subsequent  death. 

Watson,  of  New  York,  has  moreover  recorded  a  case  of 
recovery  in  the  person  of  a  man  who  fell  from  the  yard- 
arm  of  a  vessel,  breaking  his  thigh  and  arm  bones  and  both 
condyles  of  the  lower  jaw,  with  the  following  symptoms  : — 
"  His  face  was  somewhat  deformed  by  the  retraction  of  the 
chin ;  the  mouth  could  not  be  opened  so  as  to  protrude  the 
tongue  to  any  great  extent  beyond  the  teeth,  and  the  teeth 
of  the  upper  and  lower  jaw  could  not  be  brought  into 
contact.  In  attempting  to  move  the  jaw  the  patient  ex- 
perienced pain  and  crepitation  just  in  front  of  the  ears  ; 
the  crepitation  could  be  easily  felt  by  placing  the  fingers 
over  the  fractured   condyles.     Nothing   was  done    for  the 


J  4  FRACTURE    OF   THE    LOWER  JA.\Y. 

fractures  of  the  jaw.  In  a  few  weeks  the  rubbing  of  the 
broken  surfaces  and  attendant  soreness  ceased  to  trouble 
him  ;  but  the  shape  of  the  jaw  and  difficulty  of  opening 
the  mouth  to  any  great  extent  still  remained  unaltered," 
{New  York  Journal  of  Medicine,  October,  1840.) 

deduction  of  a  fracture  of  the  neck  of  the  jaw,  should 
complete  displacement  have  occurred,  can  only  be  effected 
by  acting  upon  the  condyle  and  the  jaw  at  the  same  time. 
The  finger  carried  far  back  in  the  mouth  should  throw  the 
condyle  out,  whilst  the  jaw  is  brought  into  its  proper 
relation  with  the  other  hand.  The  fragments  must  then  be 
pressed  firmly  together,  and  against  the  glenoid  cavity,  with 
a  bandage.  Eibes,  to  whom  this  plan  is  due,  applied  it 
with  success.     (Malgaigne.) 

Fracture  of  the  coronoid  process  is  a  rare  -accident.  Thus 
Hamilton  says  that  Houzelot's  case  is  the  only  one  which  he 
has  found.  Curiously  enough,  however,  he  employs  the  illus- 
tration from  Fergusson's  "  Practical  Surgery  "  a  few  pages 
before,  in  which  a  fracture  of  the  coronoid  process  is  seen, 
and  which  is  taken  from  specimen  1  in  King's  .College.  The 
fragment  would,  no  doubt,  be  drawn  upwards  and  backwards 
by  the  temporal  muscle,  and  might  be  felt  in  its  new  situa- 
tion, though  this  displacement  would  probably  be  limited 
by  the  very  tough  and  tendinous  fibres  which  are  so  closely 
connected  with  the  bone,  forming  the  insertion  of  the  temporal 
muscle,  and  reaching  down  to  the  last  molar  tooth.  Accord- 
ing to  Sanson,  fractures  of  the  coronoid  process  do  not  admit 
of  union,  but  Mr.  Holmes  ("  Principles  and  Practice  of 
Surgery")  thinks  that  this  statement  is  entirely  un- 
supported, and  that  the  idea  that  fracture  of  the  coronoid 
process  of  the  jaw  does  not  unite  by  bone  rests  on  no 
evidence. 

Considerable  inflammation  frequently  follows  a  fracture  of 
the  jaw,  even  of  a  simple  kind,  particularly  if  it  has  been 
neglected  or  overlooked  for  some  hours.  The  face  becomes 
swollen,  and  the  tissues  beneath  the  chin  infiltrated  with 
serum,  which  is  sometimes  converted  into  pus,  giving  rise  to 
troublesome  abscesses. 


15 


CHAPTEK  11. 

COMPLICATIONS    OF    FRACTURE    OF    THE    LOWER  JAW. 

Wounds  of  the  face  are  rare  accompaniments  of  fracture  of 
the  lower  jaw,  except  in  cases  of  gunshot  injury,  and  when 
found  are  usually  the  result  of  a  kick  from  a  horse.  The 
wound  itself  requires  treatment  on  ordinary  principles,  and 
is  of  little  moment  as  regards  the  fracture  (which  is  doubt- 
less "compound'"  also  into  the  mouth),  except  as  interfering 
with  the  application  of  the  necessary  retentive  apparatus. 
In  a  case  of  extensive  fracture  of  the  lower  jaw,  the  result 
of  a  kick  from  a  horse,  which  I  saw  in  the  Westminster 
Hospital,  under  Mr,  Holthouse's  care,  the  lip  and  chin  were 
extensively  torn  ;  and  in  a  case  of  Mr,  Berkeley  Hill's,  in 
University  College  Hospital,  the  result  of  a  fall,  the  wound 
beneath  the  chin  very  much  interfered  with  the  application 
of  a  modified  form  of  Lonsdale's  apparatus,  which  it  was 
found  necessary  to  employ. 

Hcemorrhage,  beyond  that  resulting  from  laceration  of  the 
gums,  is  rarely  met  with,  since,  although  theoretically  one 
might  imagine  that  the  inferior  dental  artery  would  frequently 
be  torn  across,  this  appears  not  to  be  the  case ;  a  result  due, 
no  doubt,  to  the  fact  that  the  elasticity  of  the  artery  allows 
of  its  stretching  sufficiently  to  avoid  rupture.  In  the  Lancet 
of  12th  October,  1867,  a  case  of  fractured  jaw  is  reported, 
under  the  care  of  Mr.  Maunder,  in  which  severe  haemorrhage 
into  the  mouth  occurred  through  a  fissure  in  the  gum 
behind  the  last  molar  tooth.  This  was  effectually  controlled 
by  digital  compression  of  the  carotid  artery^  which  was  main- 
tained for  two  hours  and  a  half,  after  which  no  further 
bleeding  occurred.    Secondary  hsemorrhage  has  also  been  met 


IG      COMPLICATIONS  OF  FRACTURK  OF  LOWER  JAW, 

with,  for  Steplien  Smith,  of  New  York,  reports  a  case  of 
double  fracture  in  which  about  a  pint  of  blood  was  lost  from 
the  seat  of  fracture  on  the  twentieth  day.  Injury  of  the 
soft  parts  about  the  jaws  may  give  rise  to  severe  haBmorrhage, 
requiring  prompt  treatment ;  thus  Mr.  Lawson  has  re- 
ported {Medical  Times  and  Gazette,  1862,)  a  case  in  which 
it  became  necessary  to  lay  open  the  face  in  order  to  secure 
the  facial  and  transverse  facial  arteries,  torn  by  the  wheel 
of  a  cart,  wliich  had  fractured  both  the  upper  and  lower 
jaws. 

In  the  Appendix  will  be  found  a  case  (Case  I.)  of 
compound  comminuted  fractures  of  both  upper  and  lower 
maxillic,  with  extensive  laceration  of  the  face,  in  wliich 
tracheotomy  became  necessary,  owing  to  the  urgent  dyspnoea 
supervening  a  few  hours  after  the  accident,  due,  probably, 
to  blood  becoming  infiltrated  into  the  tissues  about  the  base 
of  the  tongue.  A  case  of  death  during  the  administration 
of  chloroform,  which  occurred  at  St.  Bartholomew's  Hospital 
in  1882,  seems  to  have  l)een  due  to  injury  of  the  larynx 
and  extravasation  of  blood  into  the  muscles  of  the  root  of 
the  tongue,  accompanying  a  fracture  of  the  lower  jaw  caused 
by  a  blow  in  fighting. 

Dislocation  and  fracture  of  the  teeth  are  not  unfrequently 
met  with,  the  former  being  the  direct  result  of  a  blo"vv,  or 
the  consequence  of  the  fracture  running  through  the  socket, 
and  the  latter  the  result  of  direct  violence ;  or,  in  the  molar 
region  particidarly,  in  consequence  of  indirect  force  through 
the  neighbouring  teeth  ;  or  from  the  teeth  being  forcibly 
driven  against  tliose  of  the  upper  jaw.  (Tomes.)  Wliere 
the^  fracture  had  passed  tlirougli  tlie  socket,  the  tootli  may 
fall  between  the  edges  of  the  bone  and  prevent  their  proper 
coaptation,  and  this  should  be  borne  in  mind  when  a  tooth 
is  missing  and  difficulty  is  experienced  in  setting  a  fracture, 
since  Erichsen  mentions  a  case  where  union  was  prevented 
until  the  tooth  was  removed.  In  the  molar  region  the  crown 
of  the  tootli  may  be  broken  off,  one  fang  remaining  in  situ 
and  the  other  dropping  into  the  fracture,  as  was  the  case 
with  the  patient  under  my  own  care,  from  whom  specimen  2 


PARALYSIS  AND  NEURALGIA.         17 

of  the  King's  College  Museum  was  taken.  Teeth  which 
are  merely  loosened,  generally  become  reattached  and  useful, 
and  should  therefore  not  be  removed. 

I  am  indebted  to  Mr.  Margetson  of  Dewsbury  for  a  case  in 
which  double  fracture  of  the  jaw  occurred,  with  dislocation  of 
several  of  the  teeth,  and  fracture  of  the  left  second  bicuspid, 
the  crown  of  which  was  imbedded  for  more  than  two  years 
in  the  tissues  of  the  mouth,  behind  the  incisor  teeth.  Mr. 
Margetson  removed  the  crown  from  its  abnormal  position  and 
also  the  fang ;,  and  both,  together  with  a  plaster  cast,  showing 
very  well  the  deformity  resulting  from  the  fracture  of  the  jaw, 
are  in  the  Museum  of  the  College  of  Surgeons.      (3123.) 

The  front  teeth  may  be  broken  off,  with  the  portion  of  the 
alveolus  containing  them,  by  a  horizontal  fracture,  either 
alone  or  in  combination  with  a  vertical  fracture  through  the 
thickness  of  the  bone.  Specimen  1  of  University  College 
shows  a  vertical  fracture  through  the  symphysis,  with  a 
horizontal  fracture  running  through  the  alveolus  on  the  right 
side,  separating  the  portion  containing  the  right  lateral 
incisor,  the  canine,  and  first  bicuspid  teeth.  Such  a  frag- 
ment may  be  made  to  re-unite  if  treated  at  once,  but  when 
some  days  have  elapsed,  and  the  fragment  is  only  attached 
by  a  portion  of  gum,  removal  must  necessarily  be  performed. 
A  case  of  the  kind  was  recently  under  my  own  care,  in  the 
person  of  a  man  aged  sixty,  who  had  had  a  blow  on  the  left 
side  of  the  jaw  six  days  before  I  saw  him,  I  found  a  loose 
piece  of  alveolus  three-quarters  of  an  inch  in  length,  and 
containing  the  left  incisors  and  canine  teeth,  which  was 
merely  held  by  a  portion  of  gum,  there  being  no  other 
injury  to  the  jaw.  The  preparation  is  now  in  the  Museum 
of  the  College  of  Surgeons.      (879.) 

In  fracture  of  the  lower  jaw  in  children — a  very  rare 
accident — when  the  fracture  happens  to  involve  the  cavity  in 
which  a  permanent  tooth  is  being  developed,  exfoliation  of 
the  tooth,  with  a  portion  of  the  alveolus,  is  almost  certain 
to  ensue,  as  was  noticed  by  Mr,  Vasey  in  a  case  occurring 
in  St.  George's  Hospital. 

Paralysis  and  Neuralgia  from  injury  to  the  inferior  dental 

/r^  c 


18       COMPLICATIONS  OF  FRACTURE  OF  LOWER  JAW. 

nerve  may  be  the  immediate  result  of  the  accident,  or  be 
caused  at  a  later  period  by  some  pressure  arising  from  the 
development  of  callus.  In  by  far  the  greater  number  of 
cases  no  injury  of  the  nerves  accrues,  and  this  may  be  partly 
explained,  as  Boyer  originally  pointed  out,  by  the  fact  that 
"  the  greater  part  of  these  fractures  takes  place  between  the 
symphysis  and  the  foramen  by  which  the  nerve  comes  out." 

A  case  of  paralysis  of  the  inferior  dental  nerve,  from  a 
gunshot  wound  of  the  ramus,  which  was  under  my  care 
some  years  ago,  will  be  subsequently  referred  to ;  and 
Malgaigne  describes  a  specimen,  in  the  Musee  Dupuytren, 
also  the  result  of  gunshot  injury,  in  which  the  dental  nerve 
was  ruptured,  and  its  canal  obliterated  at  the  seat  of  frac- 
ture.     (See  Fig.  7.) 

Temporary  paralysis  of  the  inferior  dental  nerve  must  be 
of  rare  occurrence,  since  Malgaigne  did  not  meet  with  it ; 
and  Hamilton  thinks  that  "  the  explanation  may  be  found 
in  the  fact  that  the  fragments  seldom  overlap  to  any  appre- 
ciable extent,  and  that  even  the  displacement  in  the  direction 
of  the  diameters  of  the  bone  is  generally  inconsiderable,  or, 
if  it  does  exist,  it  is  easily  and  promptly  replaced."  He 
thinks,  moreover,  that  temporary  anaesthesia  of  the  chin 
might  not  improbably  be  overlooked  at  first,  and  would  have 
ceased  by  the  time  the  apparatus  was  removed.  A.  B^rard 
saw  a  case  of  vertical  fracture  without  displacement  between 
the  second  and  third  molar  teeth,  in  which  complete  tempo- 
rary anaesthesia  of  the  lip  and  chin  as  far  as  the  median 
line  existed  {Gazette  des  Hojntaux,  August  10th,  1841).  A 
case  of  temporary  paralysis  of  the  dental  nerve,  from  fracture, 
is  mentioned  also  by  Eobert  {Gazette  des  Hojntatix,  1859, 
p.  157),  occurring  in  a  woman,  aged  sixty-four,  who  M'as  run 
over  by  a  carriage,  and  wlio  also  suffered  from  fracture  and 
displacement  of  the  malar  bone,  witli  2>crmanent  anaesthesia 
of  the  infra-orbital  nerve. 

The  cases  of  convulsions  coincident  with  fracture  of  tlie 
jaw,  recorded  by  liossi  and  Flajani,  would  appear  to  have 
been  due  to  injury  of  the  brain,  the  result  of  the 
original  accident  and  imconnected  witli  the  fracture,  but  it 


INJURY   TO   BASE   OF   SKULL.  19 

may  happen  that  direct  injury  may  be  inflicted  on  the 
skull  by  the  broken  jaw.  Thus  Dr.  Lef^vre  {Journal 
Hebclomadaire,  1834)  gives  the  case  of  a  sailor,  aged  twenty- 
two,  who  fell  from  a  height  upon  his  chin  with  the  following 
result.  There  was  almost  complete  inability  to  open 
the  mouth,  the  jaws  being  tightly  closed  and  the  lower 
drawn  backwards  and  a  little  to  the  left.  There  were 
tenderness  and  ecchymosis  in  the  left  temporo- maxillary 
region,  and  a  little  blood  flowed  from  the  left  ear.  The 
case  was  diagnosed  to  be  one  of  fracture  of  the  neck  of 
the  condyle.  The  man  died  six  months  after  with  brain 
symptoms,  and  on  opening  the  head,  the  left  glenoid  cavity 
was  found  driven  in,  with  a  starred  fracture  of  the  tem- 
poral bone,  between  the  fragments  of  which  the  condyle 
of  the  jaw  was  found.  There  was  a  large  abscess  in  the 
brain. 

Similarly  in  the  Museum  of  St.  George's  Hospital,  there 
is  a  temporal  bone  with  the  unbroken  condyle  of  the  inferior 
maxilla  driven  through  the  glenoid  cavity,  producing  a 
fracture  of  the  middle  fossa  of  the  base  of  the  skull  in  a  case 
where  there  was  an  extensive  comminuted  fracture  of  the 
jaw  itself,  which,  however,  is  not  preserved.  In  contrast  with 
thisj  may  be  mentioned  another  case  which  also  occurred  in 
St.  George's  Hospital,  and  the  details  of  which  will  be  found 
in  the  Appendix  (Case  II.),  where  the  neck  of  the  condyle  and 
the  base  of  the  coronoid  process  having  been  broken  through, 
the  lower  fragment  was  displaced  and  had  produced  laceration 
of  the  meatus  auditorius  externus,  separating  the  cartilaginous 
from  the  osseous  portion  for  nearly  half  its  circumference.  In 
this  case  considerable  serous  discharge  flowed  from  the  ear, 
leading  to  the  suspicion  of  injury  to  the  skull,  but  there  were 
no  brain  symptoms,  and  the  patient  dying  with  delirium 
tremens,  the  skull,  the  membranes,  and  the  brain  were  found 
perfectly  healthy. 

In  connexion  with  these  cases  may  be  mentioned  those 
recorded  by  M.  Morvan  {Archives  G6nercdes,  1856),  who 
gives  two  cases  of  his  own,  and  one  by  Montezzia,  where  a 
blow  on  the  chin  was  followed  by  bleeding  from  the  ear ; 

0  2 


20     COMPLICATIONS  OF  FRACTURE  OF   LOWER  JAW. 

and  one  case  by  Tessier,  where  a  double  fracture  of  the  jaw 
from  a  kick  by  a  horse  was  followed  by  bleeding  from  both 
ears.     In  all  these  instances  the  patients  recovered. 

An  instance  of  neuralgia,  consequent  upon  old  fracture  of 
the  lower  jaw,  occurred  in  St.  Bartholomew's  Hospital  in 
1863.  Mr.  Wormald,  under  whose  care  the  patient  was, 
opened  up  the  dental  canal  and  excised  a  portion  of  the 
inferior  dental  nerve  with  the  most  satisfactory  result. 
{Medical  Times  and  Gazette,  April  4th,  1863.) 

Abscess  is  not  a  very  uncommon  complication  of  severe 
injuries  of  the  jaw,  the  matter  pointing  below  the  bone,  and 
being  in  some  cases  probably  as  much  the  result  of  injudi- 
cious pressure  by  retentive  apparatus  as  of  the  injury.  A 
certain  amount  of  pus  commonly  finds  its  way  into  the 
mouth  through  the  lacerated  gum  in  all-  cases  of  severe 
fracture,  but  the  exit  is  usually  sufficient  to  prevent  the 
occurrence  of  abscess  within  the  mouth.  In  neglected  cases 
of  fracture,  the  abscess  may  be  connected  with  necrosis,  and 
may  open  at  some  distance  down  the  neck,  and  remain  patent 
for  many  months ;  thus  I  am  indebted  to  Mr.  Margetson,  of 
Dewsbury,  for  a  case  where,  in  consequence  of  a  neglected 
fracture  (which  from  the  twisting  of  the  face  to  the  left  side 
would  appear  to  have  been  one  of  the  neck  of  the  left 
condyle),  three  years  after  the  receipt  of  the  injury  there 
was  still  a  fistulous  opening  on  the  left  side  of  the  neck, 
about  two  inches  below  the  angle  of  the  jaw. 

Salivary  fistula  may  result  from  a  compound  fracture  of 
the  lower  jaw,  or  from  an  abscess  bursting  externally  in  the 
case  of  a  simple  fracture.  The  treatment  would  of  course 
be  that  for  salivary  fistula,  arising  from  other  causes,  such 
as  necrosis,  &c.  In  the  Appendix  will  be  found  a  case 
(Case  III.)  occurring  under  the  author's  care,  in  which 
a  salivary  fistula  was  connected  with  necrosis  and  false 
joint  in  the  ramus  of  tlie  jaw,  following  a  gunshot  injury, 
and  which  was  successfully  closed. 

Necrosis  to  the  extent  of  small  portions  of  the  alveolus 
not  unfrequently  follows  fracture  of  the  jaw,  and  without 
any  permanent  deformity  occurring ;  but  when  the  necrosis 


NECROSIS    AND    ITS    RESULTS. 


21 


affects  the  whole  thickness  of  the  bouej  as  may  happen  when 
the  fracture  is  comminuted,  and  a  portion  becomes  so 
detached  as  to  lose  its  vitality,  the  consequent  deformity  may 
be  very  great.     Of  this  a  specimen  in  St.  George's  Hospital 


Fia.  4. 


Museum  (fig.  4)  affords  a  good  example,  a  loss  of  substance 
to  the  right  of  the  symphysis  having  occurred,  leading 
to  the  union  of  the  halves  of  the  bone  at  an  acute  angle. 


Fig.  5. 


Fig.  6. 


#\ 


A  still  better  example  of  the  same  kind  of  deformity,  and 
from  a  similar  cause,  is  .seen  in  fig.  5,  taken  fi'om  a  model 


22   COMPLICATIONS  OF  FRACTUEE  OF  LOWER  JAW. 

lent  to  me  by  Mr.  Hepburn.  The  patient  several  years  ago 
received  a  kick  from  a  horse,  which  produced  a  compound 
comminuted  fracture  of  the  lower  jaw.  The  central  portion 
became  necrosed  and  was  removed  by  the  late  Mr.  Aston 
Key,  and  appears  to  have  extended  from  the  second  bicuspid 
tooth  of  the  right  side  to  the  first  molar  on  the  left,  the 
intervening  teeth  being  wanting.  The  result,  as  seen  in  the 
model,  is  that  the  two  halves  of  the  jaw  are  united  at  an 
angle,  of  which  the  second  bicuspid  tooth  forms  the  apex, 
the  jaw  being  so  much  contracted  that  this  tooth  is  three- 
quarters  of  an  inch  behind  the  upper  incisor,  as  can  be  well 
seen  in  fig.  6.  Here,  by  the  skilful  adaptation  of  artificial 
apparatus,  Mr.  Hepburn  has  been  enabled  to  restore  the 
power  of  mastication  and  articulation,  which  was  previously 
much  impaired,  so  that  the  patient  (a  clergyman)  is  able  to 
perform  his  duties  with  satisfaction. 

A  remarkable,  and  I  imagine  unique,  case  of  necrosis  and 
exfoliation  of  the  two  halves  of  the  symphysis  menti  oc- 
curred to  Mr.  Henry  Power,  who  has  been  good  enough  to 
give  me  the  details  of  the  case.  Here  the  patient  sus- 
tained a  compound  fracture  of  the  symphysis  by  a  severe 
fall,  and  some  months  after,  during  the  whole  of  which 
time  profuse  suppuration  was  going  on  in  the  part,  two  thin 
lamellte  of  bone,  apparently  the  surfaces  of  the  symj)hysis, 
came  away,  after  which  rapid  solidification  of  the  fracture 
ensued. 

Boyer,  in  his  lectures,  mentions  having  extracted  from  a 
fistula  in  the  meatus  auditorius  externus,  the  necrosed 
condyle  of  a  man  who  had  had  a  fracture  of  the  neck  of  the 
bone  seven  or  eight  months  before. 

Dislocation. — I  have  been  able  to  find,  in  the  standard 
authors,  the  records  of  only  two  cases  of  fracture  of  the  body 
of  the  jaw  complicated  by  dislocation  of  the  condyle  from 
the  glenoid  cavity,  and  the  accident  must  of  necessity  be  a 
rare  one,  for  the  fact  of  fracture  having  occurred  would 
tend  to  prevent  the  dislocation,  since  the  leverage  necessary 
would  thus  be  interfered  with.  The  cases  in  question  are 
given  by  Malgaigne  in  his  work  on  "  Dislocations,"  one  being 


DISLOCATION   WITH   FRACTURE.  23 

recorded  by  Delamotte,  who  saw  a  fracture  of  the  body  of 
the  jaw  with  double  dislocation,  produced  by  the  kick  of  a 
horse  in  a  girl  of  between  eleven  and  twelve  years.  The 
other  was  a  more  remarkable  case^  recorded  by  Eobert,  who 
saw  a  dislocation  of  the  left  condyle  outwards,  with  fracture 
of  the  jaw  in  front  of  the  right  ramus,  in  a  man  who  was 
knocked  down  on  his  left  cheek,  the  wheel  of  a  carriage 
passing  over  the  right. 

A  third  case,  however,  is  reported  by  Mr.  Croker  King 
(DubUn  Hosintcd  Gazette,  1855),  and  occurred  in  a  boy  of 
eight,  who  suffered  a  fracture  at  the  symphysis  with  dislo- 
cation of  the  left  condyle  upwards  and  backwards.  There 
was  bleeding  from  the  ear,  and  the  chin  was  much  retracted 
and  turned  to  the  left ;  the  mouth  was  open,  but  could  be 
closed,  and  it  was  then  observed  that  the  lower  molars  over- 
lapped the  upper,  but  that  the  lower  incisors  were  at  least 
one  inch  hehind  the  upper.  Eeduction  was  easily  effected, 
and  the  case  did  well.  (Owing  to  an  obscurity  and  apparent 
contradiction  in  the  report,  this  case  has  been  put  down  by 
Weber  as  an  instance  of  unusual  dislocation  %uithout  fracture.) 

A  fourth  case  of  the  kind  is  also  briefly  referred  to  by 
Mr.  Gunning,  of  New  York,  in  his  paper  on  "  Interdental 
Splints."  {Neio  York  Medical  Journal,  1866.)  "  The  patient 
was  thirty-six  years  old;  the  jaw  was  fractured  through 
the  symphysis  and  the  right  condyle  dislocated  outivard  and 
hackivard,  February  10th,  1866,  in  falling  down  stairs  and 
striking  the  chin  on  a  small  desk.-"  The  dislocation  was 
reduced  before  Mr.  Grunning  was  called  in. 

The  case  of  fracture  of  the  glenoid  cavity  by  the  dis- 
placed condyle  in  St.  George's  Hospital,  already  referred  to, 
cannot  be  regarded  as  one  of  true  dislocation.  The  treat- 
ment in  these  cases  would  of  course  be  reduction  of  the 
dislocation  before  setting  the  fracture. 

In  fractures  of  the  neck  of  the  jaw  the  condyle  itself  has 
been  found  displaced.  Thus  Holmes  Coote  (in  his  article  on 
Injuries  of  the  FacC;  Holmes'  "  System  of  Surgery,"  vol.  ii.) 
mentions  that  Bonn,  writing  in  1783,  gives  an  account  of 
a  case  of  the  kind.    There  was  a  lon<fitudinal  fracture  in  the 


24   COMPLICATIONS  OF  FRACTURE  OF  LOWER  JAW. 

middle  of  the  bone,  and  at  the  same  time  the  right  condyle 
was  broken  off  and  dislocated  forwards  and  inwards,  lying 
united  by  callus  near  the  foramen  ovale.  The  pointed  ujiper 
extremity  of  the  neck  of  the  lower  jaw  articulated  with  the 
glenoid  cavity,  and  the  separated  head  with  the  lateral  part 
of  the  tubercle  of  the  temporal  bone.  There  was  motion  in 
the  false  joint.  The  same  author  mentions  a  case  of  fracture 
and  dislocation  of  both  condyles  of  the  lower  jaw,  in  a 
young  man  who  had  numerous  injuries  and  lived  five  weeks. 
The  condyles  were  found  to  be  broken  off,  and  fixed  near 
the  foramen  on  either  side. 

Irregidar  Union. — Where  the  displacement  of  the  frag- 
ments has  been  great,  it  may  be  imi^ossible  to  keep  them 
in  proper  ^^osition,  and  the  result  may  be  an  irregular  union 
of  the  bone,  interfering  more  or  less  with  its  functions  in 
after-life.  This  is  particularly  liable  to  occur  in  cases  of 
double  fracture,  where  the  central  portion  of  the  jaw  is 
much  displaced  by  the  muscles  attached  to  itj  and  Mal- 
gaigne  gives  a  drawing  from  a  specimen  of  the  kind  in 
the  Musee  Dupuytreu  (fig.  7),  in  which  the  middle  fragment 

Fig.  7. 


is  displaced  downwards  and  backwards,  and  has  also  under- 
gone such  a  change  of  position  that  its  lower  border  is  in- 
clined forward,  and  its  anterior  surface  looks  almost  directly 
upwards,  the  union  on  one  side  being  partly  fibrous. 

An  almost  precisely  similar  state  of  things  existed  in  a 
case  of  double  fracture  wliich  came  under  Mr.  Bickersteth's 


NON-UNION   AND   FALSE  JOINT.  25 

care,  and  wliich  will  be  found  in  detail  under  the  head  of 
"  Treatment  of  Ununited  Fracture/'  the  central  portion  of 
the  jaw  having  become  much  depressed,  and  united  on  one 
side,  so  that  when  the  molars  were  in  contact  the  incisor 
teeth  were  separated  more  than  half  an  inch,  the  opposite 
fracture  being  still  ununited.  Here  Mr.  Bickersteth  reme- 
died the  deformity  by  sawing  through  the  bone  at  the  seat 
of  the  united  fracture,  and  replacing  the  fragment  in  its 
proper  position. 

The  specimen  of  united  fracture  in  University  College 
Museum  illustrates  very  well  the  effect  of  irregular  union 
upon  the  teeth,  and  the  masticatory  power  of  the  jaw.  The 
fracture  was  in  the  right  molar  region,  and  appears  to  have 
led  to  the  loss  of  all  the  teeth  on  that  side  except  the  last 
molar.  The  irregular  union  has  resulted  in  a  contraction 
of  the  alveolar  arch,  so  that  the  left  teeth  have  been  thrown 
within  those  of  the  upper  jaw,  with  the  result  of  wearing 
away  the  opposed  surfaces  of  the  two  sets — viz.,  the  lower 
teeth  on  their  outer  and  the  upper  on  their  inner  surfaces. 
Hamilton  expresses  an  opinion,  "that  time  and  the  constant 
use  of  the  lower  jaw  in  mastication  will  gradually  effect  a 
marked  improvement  in  the  ability  to  bring  the  opposing 
teeth  into  contact."  The  specimen  above  referred  to  illus- 
trates the  only  mode  in  which  such  an  improvement  could, 
in  my  opinion,  occur. 

The  deformity  resulting  from  loss  of  a  portion  of  the 
bone  near  the  symphysis,  has  been  already  referred  to  under 
the  head  of  "  Necrosis."  Loss  of  substance  in  other  parts 
of  the  jaw  is  apt  to  result  in  fibrous  union  or  false  joint, 
and  this  is  especially  the  case  in  gunshot  injuries. 

JSfon-union  and  False  Joint. — Fractures  of  the  lower  jaw 
ordinarily  unite  with  great  rapidity  and  certamty,  notwith- 
standing the  difficulties  often  met  with  in  maintaining  perfect 
apposition  of  the  fragments.  Hamilton  has  noticed  one 
instance,  in  an  adult  person,  in  which  the  bone  was  im- 
movable at  the  seat  of  fracture  on  the  seventeenth  day,  and 
says  that  in  no  instance  under  his  own  observation  has  the 
bone   refused    finally   to  unite,   although    union   has   been 


26     COMPLICATIONS  OF  FRACTURE  OF  LOWER  JAW. 

delayed  as  loug  as  eleven  weeks.  Cases  of  non-union  and 
false  joint  have,  however,  been  recorded  and  treated  by 
Physick,  Dupuytren,  and  others  ;  and  a  case  has  already 
been  referred  to  which  occurred  under  my  own  care,  in 
which  false  joint  followed  a  gunshot  injury  of  the  ramus  of 
the  jaw.  (See  Appendix,  Case  III.)  The  liability  of  the 
lower  jaw  to  false  joint,  as  compared  with  other  bones,  may 
be  gathered  from  a  table  of  150  cases  drawn  up  by  Norris 
(American  Journal  of  Medical  Scicjices,  January,  1842).  Of 
these  150  cases  48  occurred  in  the  femur,  48  in  the  humerus, 
33  in  the  leg,  19  in  the  forearm,  and  two  in  the  lower 
jaw. 

Non-union  may  be  simply  the  result  of  neglect  of  treat- 
ment, and  union  may  take  place  readily  as  soon  as  the  parts 
are  placed  under  favourable  circumstance.  "  Thus  a  patieut 
was  under  Mr.  Wormald's  care  who,  five  weeks  before  ad- 
mission into  St.  Bartholomew's  Hospital,  had  fractured  his 
jaw  between  the  canine  and  bicuspid  teeth  on  the  left  side, 
for  which  he  had  not  been  treated.  There  was  some  little 
necrosis,  and  sinuses  had  already  formed  beneath  the  chin;  but 
under  appropriate  treatment  the  bone  thoroughly  united  in 
five  weeks.  {Medical  Times  and  Gazette,  Jan.  17,  1863.) 
And  yet,  on  the  other  hand,  fracture  of  the  jaw  has  no 
doubt  been  occasionally  untreated,  and  still  has  united. 
Thus  Boyer  saw  consolidation  occur,  though  not  without 
deformity,  in  a  water-carrier  who  would  not  endure  any 
dressing,  nor  abstain  from  either  speaking  or  chewing  when 
the  pain  did  not  prevent  him.  Notwithstanding  the  most 
careful  treatment,  however,  the  jaw  may  fail  to  unite  if  the 
case  has  been  complicated  in  any  way.  Thus  Mr.  Berkeley 
Hill  mentions  a  case  {British  Med.  Journal,  March  2,  1867) 
of  double  fracture,  where  great  difficulty  was  experienced  in 
adapting  suitable  apparatus,  and  where  one  fracture  united 
perfectly,  but  the  other  remained  ununited.  And  again, 
on  the  other  hand,  over-solicitous  attention  appears  occa- 
sionally to  interfere  with  union ;  for  A.  Berard  relates  the 
singular  case  of  a  cliild  whose  fracture  made  no  progress 
towards  recovery  till  the  apparatus,  an  ordinary  bandage, 
was  removed  ;  and  Mr.  Hill's  case,  mentioned  above,  illus- 


UNUNITED   FRACTURE.  27 

trafces  the  same  point,  for  he  informs  me  that  the  second 
fracture  became  consolidated  without  any  treatment. 

The  occurrence  of  necrosis  at  the  point  of  fracture  is  the 
most  probable  cause  of  non-union,  and  a  small  amount  of 
this  may  prevent,  or  at  least  delay,  the  union  taking  place, 
as  in  Mr.  Power's  case,  where  two  thin  lamellae  exfoliated 
from  the  symphysis  ;  and,  moreover,  callus  is  not  thrown 
out  so  copiously  for  the  repair  of  fractures  of  the  jaw  as 
it  is  in  the  long  bones.  Gunshot  injuries  seem  especially 
liable  to  produce  ununited  fractures  of  the  lower  jaw, 
probably  by  inducing  necrosis  ;  and  of  this  an  example 
under  the  author's  care  has  been  already  alluded  to.  On 
tins  subject  the  late  Dr.  Williamson,  of  Fort  Pitt,  has 
made  the  following  observations  in  his  work  on  "  Military 
Surgery,"  p.  22: — 

"  Ununited  fracture  of  the  lower  jaw  does  not  seem  to 
have  been  of  such  frequent  occurrence  amongst  the  wounded 
from  the  Crimea  as  those  from  India.  Six  were  admitted 
from  India  with  fracture  of  the  lower  jaw.  Of  these  three 
were  invalided,  two  sent  to  duty,  and  one  to  modified  duty. 
Of  these  six  cases,  three  were  instances  where  the  fracture 
remained  still  ununited,  though  the  ends  of  the  bone  were  in 
contact.  In  one  case  the  ball  struck  one  side  of  the  lower 
jaw,  and  was  cut  out  on  the  opposite  side  one  month  after, 
fracturing  the  bone  on  both  sides.  In  one,  the  ball  was 
cut  out  from  below  the  tongue.  In  one  case,  from  a  shell 
wound,  there  was  a  double  fracture,  one  on  the  right  side 
of  the  ramus,  and  also  another  near  the  symphysis,  with 
great  laceration  of  soft  parts,  and  resulting  deformity ;  the 
first-named  fracture  remained  ununited.  In  another  case 
there  was  a  double  fracture  from  a  musket-ball ;  the  frac- 
ture at  the  entrance  of  the  ball  still  remains  ununited ; 
that  at  the  exit  has  become  united.  In  one  case,  from 
round  shot,  the  whole  of  the  left  ramus  of  the  lower  jaw 
had  been  extracted  at  tlie  time,  or  came  away  by  exfolia- 
tion, leaving  a  large  chasm  and  great  deformity  on  tliis  side 
of  the  cheek  from  laceration  of  the  soft  parts.  In  one  case 
there  was  a  fracture  on  the  left  side,  at  the  angle  of  the 
jaw,  still  ununited. 


28       COMPLICATIONS   OF  FRACTURE   OF  LOWER  JAW. 

"  Attempts  were  made  to  excite  action  in  the  ends  of  the 
bone  by  forcibly  rubbing  together,  and  afterwards  keeping 
the  two  fracture  ends  at  rest  by  wire  round  the  teeth,  and 
a  piece  of  cork  placed  between  the  teeth  of  the  posterior 
fragment  and  that  of  the  upper  jaw,  but  without  success. 
It  was  not  thought  advisable  to  try  the  effects  of  a  seton 
or  other  means  of  inducing  the  effusion  of  new  bone.'" 

Piokitansky,  in  his  "  Pathological  Anatomy"  (Sydenham 
Society's  Translation,  iii.  p.  216),  describes  the  unnatural 
joints  resulting  from  fracture  as  of  two  kinds;  "one  more 
or  less  resembling  a  synarthrosis,  the  other  like  a  diar- 
throsis,  and  accordingly,  in  its  proper  sense,  a  new  joint. 
In  the  former  case,  the  fractured  ends  of  the  bone  are  held 
together  by  a  ligamentous  tissue.  Either  a  disc  of  ligament 
the  thickness  of  which  may  vary,  is  interposed  between 
them,  and  allows  of  but  little  movement,  or,  as  occurs 
when  there  has  been  loss  of  substance  either  from  injury, 
absorption  of  the  fractured  ends,  or  otherwise,  ligamentous 
bands  connect  the  fragments,  and  allow  them  to  move  freely 
on  each  other.  The  connecting  tissue  appears  to  be  nothing 
more  than  tlie  intermediate  substance,  which  has  failed  to 
become  transformed  into  the  secondary  callus  and  remains 
in  its  first  state. 

In  the  second  case,  a  ligamentous  articular  capsule  is 
formed,  and  is  lined  by  a  smooth  membrane  which  secretes 
synovia.  The  fractured  surfaces  adapt  themselves  to  each 
other  and  become  covered  with  a  layer  of  tissue  which  is 
fibro-ligamentous,  or  more  or  less  fibro-cartilaginous,  or 
which  resembles  and  sometimes  (Howship)  really  is  carti- 
lage. They  may  articulate  immediately  with  one  another, 
or  may  have  between  them  an  intervening  layer  of  ligament 
which  corresponds  to  an  interarticular  cartilage ;  and  tlieir 
movement  upon  each  other  is  more  or  less  free,  according 
to  the  size  of  the  articular  capsule  and  the  form  of  the 
articulating  surfaces.  These  last  are  sometimes  horizontal, 
(]»lane  ?)  and  smooth  ;  they  glide  over  each  other,  and  allow 
of  restricted  motion  ;  sometimes  one  surface  becomes  convex 
and    the  other  concave ;  sometimes  both  are  rounded  off, 


FIBROUS    UNION   OF   FRACTURE. 


29 


aud  lying  within  a  capacious  articular  capsule  far  apart, 
they  come  in  contact  only  during  particular  movements. 
The  articulating  capsule  is  the  product  of  the  inflammation 
of  the  soft  parts ;  the  cartilaginiform  layer  which  covers  the 
ends  of  the  bone  is  secondary  callus  arrested  in  its  meta- 
morphosis and  converted  into  a  fibroid  tissue.  The  other 
ligamentous  cords  which  are  sometimes  present,  aud  the 
structures  resembling  an  interarticular  cartilage,  are  rem- 
nants of  the  intermediate  substance.  Both  forms  of  new 
joint,  but  more  particularly  the  synarthrodia!  form,  have  an 
analogue  in  the  lateral  new  joints  sometimes  formed  be- 
tween the  masses  of  callus  thrown  out  around  two  adjoining 
fractured  bones." 

The  only  museum  specimen  of  ununited  fracture  of  the 
lower  jaw  I  have  met  with  is  in  University  College  (fig.  8),  and 

Fig.  8. 


belongs  to  Eokitansky's  first  division,  since  it  is  a  good  ex- 
ample of  fibrous  union  filling  the  interval  between  the  right 
canine  tooth  and  the  ramus  of  the  jaw,  there  having  evidently 
been  considerable  loss  of  bony  substance  at  the  seat  of  frac- 
ture. A  very  similar  specimen  is,  I  am  informed,  in  the 
Museum  of  the  Eoyal  College  of  Surgeons  of  Edinburgh, 
the  fibrous  tissue  extending  from  the  symphysis  to  the  left 


30      COMPLICATIONS  OF   FKACTURE   OF  LOWER  JAW. 

bicuspid  teeth.  I  have  no  doubt,  however,  that  the  other 
form,  the  true  false  joint,  does  occur  in  the  lower  jaw  both 
as  the  result  of  violence  (and  particularly  in  the  ramus  of 
the  jaw)  and  as  the  result  of  operative  interference,  having 
had  the  opportunity  of  watching  the  formation  of  a  false 
joint  in  two  cases  in  which  I  performed  Esmarch's  opera- 
tion for  closure  of  the  jaws,  which  will  be  referred  to  in 
another  part  of  this  essay. 

The  amount  of  inconvenience  which  the  patient  expe- 
riences from  an  ununited  fracture  of  the  jaw  will  vary  ac- 
cording to  the  position  of  the  false  joint.  In  the  ramus  it 
appears  to  give  very  little,  if  any,  inconvenience,  the  new 
joint  performing  the  function  of  the  temporo-maxillary  arti- 
culation ;  and  the  same  may  be  said,  according  to  my  expe- 
rience, of  the  false  joints  purposely  made  for  the  relief  of 
closure  of  the  jaws,  although  in  the  body  of  the  bone,  since 
the  portion  of  the  jaws  posterior  to  the  joint  is  immovably 
fixed  by  the  cicatrices.  When,  however,  a  false  joint  occurs 
in  the  body  of  an  otherwise  natural  bone  great  inconvenience 
results,  the  patient  being  unable  to  masticate  properly  ;  and 
his  health  is  apt  to  suffer,  as  was  the  case  with  Dr.  Physick's 
patient,  who  was  successfully  treated  by  the  use  of  the  seton 
eighteen  months  after  the  accident.  Here  the  fracture,  ori- 
ginally double,  united  on  the  right  side,  but  the  left,  which 
was  broken  obliquely,  remained  ununited.  (Philadel2)hia 
Journal  of  Med.  and  Phys.  Sciences,  vol.  v,  p.  116.)  A  case 
is  related  also  by  Horeau  {Journal  de  MMecine,  par  Corvi- 
sart,  X.  p.  195),  which  shows  the  inconveniences  experienced. 
A  colonel  received  a  gunshot  wound  which  broke  the  right 
side  of  the  body  of  the  jaw  some  lines  from  its  junction  with 
the  ramus,  resulting  in  a  false  joint  between  the  first  and 
second  molar  teeth.  In  the  ordinary  condition  of  things 
these  two  teeth  were  on  the  same  level,  and  they  were  not 
deranged  even  by  pushing  the  fragments  from  behind  for- 
ward or  from  before  backward.  But  if  the  posterior  frag- 
ment was  raised  and  the  anterior  depressed,  the  second  molar 
tooth  was  several  lines  above  the  level  of  the  first.  The  re- 
sult was  great  difficulty  in  chewing  on  the  injured  side,  and 


UNUNITED   FHACTURE. 


31 


consequently  tlie  food  was  habitually  carried  to  the  left 
molar  teeth,  and  its  trituration  was  neither  easy  nor  com- 
plete. The  digestion  became  impaired,  and  the  patient 
suffered  from  pain  after  food,  &c.  I  have  recently  seen  a 
gentleman  whom  I  attended  some  years  ago  with  Mr. 
Moger,  of  Highgate,  and  who  had  received  most  serious 
injuries  of  the  face  from  the  pole  of  a  waggon.  In  this 
case  the  patient  barely  escaped  with  his  life,  owing  to  ery- 
sipelas and  great  constitutional  disturbance.  There  was 
double  fracture  with  extensive  necrosis  of  the  lower  jaw, 
which  has  resulted  in  a  false-joint  on  the  right  side  ;  but  for 
this  the  patient  has  declined  all  treatment,  whether  surgical 
or  mechanical,  and  though  he  is  quite  incapacitated  for 
mastication,  he  is  well  nourished  by  means  of  food  passed 
through  a  mincing-machine. 

A  remarkable  case  of  ununited  fracture  in  the  mental 
region,  the  result  of  gunshot  injury  in  the  Crimea,  is 
recorded  by  the  late  Mr.  Cox  Smith,  of  Chatham  {Dental 
Review,  1858-9),  and  was  satisfactorily  treated  mechanically 
by  that  gentleman.  The  condition  of  the  parts  was  briefly 
as  follows : — The  symphysis  with  the  incisors,  right 
canine,  and  one  bicuspid  tooth,  having  been  carried  away, 
the  jaw  was  divided  into  two  unequal  portions,  which 
fell  together  when  at  rest ;  but  upon  opening  the  mouth 
Fig.  9.  Pig.  10. 


the  left  only  was  fully  acted  upon   by    the  muscles  and 
the    right    rode    over    it,    as    shown    in    tlie    illustration 


32      COMPLICATIONS  OF  FRACTURE   OF  LOWER  JAW. 

(fig.  9).  Much  pain  was  caused  by  any  attempt  to  separate 
the  two  fragments  so  as  to  make  them  correspond  to  the 
teeth  of  the  upper  jaw ;  hence  mastication  was  impossible, 
articulation  was  much  interfered  with,  and  the  patient  could 
only  sleep  on  liis  back,  since  lying  on  either  side  caused  dis- 
placement of  the  corresponding  section  of  the  jaw.  Fig.  10 
shows  the  model  first  taken  by  Mr.  Smith,  and  its  resemblance 
to  cases  of  united  fracture  with  loss  of  substance  in  the  incisor 
region  previously  described,  will  be  at  once  noticed.  The 
treatment  of  this  interesting  case  will  be  referred  to  under 
another  section. 

The  case  of  ununited  fracture  successfully  treated  by 
Dupuytren  was  also  the  result  of  a  gunshot  injury,  and  the 
following  was  the  condition  of  the  parts  when  the  patient 
came  under  that  surgeon's  care,  four  years  "after  the  receipt 
of  the  injury  (Dupuytren's  Lcgons  Or  ales,  vol.  iv.).  The  ball 
had  struck  the  right  side  of  the  jaw  just  in  front  of  the 
masseter,  and  had  carried  away  a  portion  of  the  bone  at  the 
junction  of  the  body  with  the  ramus.  The  posterior  frag- 
ment, which  contained  the  wisdom  tooth,  was  twisted  so  that 
the  tooth  looked  towards  the  tongue,  and  at  the  same  time 
was  drawn  outwards  into  the  cheek.  The  anterior  fragment 
formed  by  the  remainder  of  the  bone  was  displaced  so  that 
its  fractured  end  was  carried  to  the  right  side  and  below  the 
other,  an  interval  of  an  inch  intervening,  corresponding  to 
the  first  and  second  molar  teeth  which  had  been  carried 
away.  The  riding  of  the  fragments  was  so  great  that  the 
second  bicuspid  tooth  was  in  contact  with  the  wisdom  tooth, 
when  the  parts  were  left  to  themselves ;  but,  when  traction 
was  made,  a  space  of  an  inch  was  produced  between  them. 
Of  course  therefore  the  teeth  of  the  two  jaws  did  not 
correspond,  and  there  was  consequently  great  difficulty  of 
mastication,  which  was  increased  by  the  want  of  power  in 
the  jaw  itself.  If  unsupported  by  a  bandage  the  jaw  drojiped, 
the  mouth  remained  open  arid  saliva  dribbled  out,  the  chin 
being  carried  over  to  the  right  side. 


33 


CHAPTER  III. 

TllEATMENT    OF    FRAOTUKED    LOWER    JAW. 

The  treatment  of  fractured  lower  jaw  after  tlie  reduction 
of  any  displacement^  the  occasional  difficulties  of  which  have 
been  alluded  to  in  a  previous  section,  is  usually  of  a  simple 
character ;  but  cases  sometimes  arise  in  which  the  most 
carefully  adapted  mechanical  contrivances  fail  to  effect  a 
good  union.  The  apparatus  employed  for  the  maintenance 
of  the  fractured  portions  in  apposition  may  be  conveniently 
divided  into  two  classes,  external  and  internal  to  the  mouth, 
though  it  may  be  necessary  to  combine  the  two  methods  in 
a  few  instances. 

The  simplest  form  of  external   apparatus  consists  of  the 

Fig.  11. 


ordinary  four-tailed  bandage  or  sling,  with  a  slit  for  the  chin 
to  rest  in  (fig.  11).      This  is  made  of  a  piece  of  bandage 


34         TREATMENT   OF    FRACTUKED    LOWER   JAW. 

about  a  yard  long  and  three  inches  wide,  which  should  have 
a  slit  four  inches  long  cut  in  the  centre  of  it,  parallel  to 
and  an  inch  from  the  edge.  The  ends  of  the  bandage  should 
then  be  split  to  within  a  couple  of  inches  of  the  slit,  thus 
forming  a  four-tailed  bandage  with  a  hole  in  the  middle. 
The  central  slit  can  be  readily  adapted  to  the  chin,  the 
narrow  portion  going  in  front  of  the  lower  lip,  and  the 
broader  beneath  the  jaw ;  and  the  two  tails  corresponding 
to  the  lower  part  of  the  bandage  are  then  to  be  carried  over 
the  top  of  the  head,  wliile  the  others  are  crossed  over  them 
and  tied  round  the  nape  of  the  neck.  The  ends  of  the 
two  bandages  may  then  be  knotted  together,  as  seen  in  the 
illustration. 

A  single  roller  may  be  employed  to  support  the  jaw,  as 
recommended  by  the  American  surgeons  Gibson  and  Barton  ; 
l)ut  this  is  more  difficult  of  application,  and  is  more  apt  to 
become  disarranged. 

Combined  with  the  sling,  a  well  padded  splint  of  either 
pasteboard  or  gutta-percha  may  be  often  advantageously 
employed.  The  material  which  is  selected  being  cut  long 
enough  to  pass  well  up  to  the  sides  of  the  jaw,  is  to  be  divided 
at  the  ends,  so  as  to  resemble  the  four-tailed  bandage  (fig.  12). 
Being  then  softened  in  warm  water  it  can  be  lined  with  lint 
or  some  soft  material  and  adapted  to  the  jaw,  the  chin  rest- 
ing on  its  centre,  and  the  sides  beino'  doubled  around  and 
beneatli  tlie  bone,  as  in  fig.  13. 

Fig.  12.  Fig.  13. 


Hamilton  states  that  he  has  frequently  noticed  the  ten- 
dency of  the  sling,  as  ordinarily  constructed,  to  carry  the 
anterior  fragment  backwards,  especially  when  there  isa  double 
fracture.  He  has  devised  a  special  form  of  a])paratus  (fig.  14) 


HAMILTON  8   SLING. 


35 


for  which  lie  claims  the  following  ; — "  The  advantage  of  this 
dressing  over  any  which  I  have  yet  seen  consists  in  its 
capability  to  lift  the   anterior  fragment  vertically  ;  and,  at 

Fig.  14. 


the  same  time,  it  is  in  no  danger  of  falling  forwards  and 
downwards  upon  the  forehead.  If,  as  in  the  case  of  most 
other  dressings,  the  occipital  stay  had  its  attachment  oppo- 
site to  the  chin,  its  effect  would  be  to  draw  the  central 
fragment  backwards.  By  using  a  firm  piece  of  leather  as  a 
maxillary  band  and  attaching  the  occipital  stay  above  the 
ears,  this  difficulty  is  completely  obviated." 

Ligature  of  the  teeth  with  silk  or  wire  is  a  method 
which  has  frequently  been  employed  for  the  treatment  of 
fractured  jaw,  but  is  unsatisfactory,  from  the  loosening  of 
the  teeth  and  irritation  of  the  gums  which  are  apt  to  be 
produced.  When  employed,  care  should  be  taken  to  select, 
if  possible,  perfectly  sound  teeth  around  which  to  apply 
the  ligature,  which  should  be  prevented  from  sinking  down 
to  the  neck  of  the  tooth  so  as  to  cut  the  gum.  An 
astringent  wash  should  be  frequently  employed  during  the 
treatment  to  maintain  the  healthy  firmness  of  the  gums 
themselves. 

P  2 


36 


TREATMENT  OF  FRACTURED  LOWER  JAW. 


A  more  satisfactory  apparatus  is  the  wire-splint  devised 
by  Mr.  Hammond,  L.D.S.,  of  Leinster  Square,  who  has 
kindly  supplied  the  following  details  of  the  method  of  apply- 
ing it. 

To  malxc  the  Hammond  Wire-splint. — After  bringing  the 
broken  parts  into  aj)position,  tie  them  temporarily  together 
with  silk  passed  outside  the  second  tooth  on  each  side  of 
the  line  of  fracture. 

With  a  suitable  "  tray"  and  very  soft  wax,  take  an 
impression  of  the  mouth  (which  need  not  be  deeper  than  the 
teeth),  supporting  the  chin  while  doing  so  with  the  left  hand. 

Fig.  15. 


Make  a  model  of  this  in  plaster  of  Paris  in  the  usual  way. 
If  there  has  been  any  displacement  of  the  parts,  saw  down 
between  the  teeth  corresponding  to  tlie  fracture,  adjust  the 
several  pieces  to  the  proper  "  bite,"  and  fix  in  position. 

Now  take  a  length  of  iron  wire  (stout  hair-pin  size)  and 
carefully  make  a  frame  to  fit  round  tlie  teeth,  soldering  the 
ends    together    with    silver    solder.     Cut  several  five-inch 


THE   HAMMOND   WIRE-SPLINT. 


37 


lengths  of  fine  soft  iron  binding  wire — both  ends  of  which 
should  be  cut  to  points,  which  will  greatly  facilitate  the 
passing  of  them  through  the  tartar  between  the  teeth.  Should 
there  be  much  tartar  a  fine  "  broach"  may  be  necessary. 

To  aii'ply  the  Splint. — Place  the  patient  upright  in  a  high- 
backed  chair,  and  rinse  the  mouth.  Slip  the  frame  over 
the  teeth,  holding  it  gently  in  place  with  the  left  hand,  and 

Fig.  16. 


with  the  right  hand  take  one  of  the  pointed  wires  and  pass 
it"  between  the  first  and  second  molars  on  the  left  side, 
directing  it  slightly  downwards  so  that  the  end  will  come 
out  under  the  inner  bar  of  the  frame.  Have  the  forefinger 
of  the  left  hand  inside  to  feel  for  the  point,  and  with  it  turn 
the  wire  upwards  and  outwards  so  as  to  avoid  wounding  the 
tongue.  Then  bring  this  wire  back,  as  shown  in  fig.  16, 
i.e.,  over  the  inner  bar  of  the  frame,  and  under  the  outer ; 
cross  the  ends  and  turn  them  aside— repeat  this  on  the 
right  side  of  the  mouth.  When  all  the  ligatures  are  passed, 
seize  the  ends  of  the  first  wire  with  a  small  pair  of  pliers, 
and  twist  them  on  each  other  nearly  tight,  doing  the  same 


38    TREATMENT  OF  FRACTURED  LOWER  JAW. 

on  the  left  side,  and  when  the  pressure  is  equalized  cut  ulf 
the  wires  about  half  an  inch  from  the  frame,  as  at  B.  Now 
twist  all  the  ligatures  quite  tight,  and  tuck  them  away  under 
the  frame,  as  at  C.  The  jaw  will  now  be  found  perfectly 
firm,  and  the  patient  able  to  bite  steadily  on  it  without 
pain. 

It  will  be  found  after  a  few  days  that  the  ligatures  will 
require  twisting  a  little  tighter  (owing  to  the  movement  of 
the  teeth  in  their  sockets},  this  can  easily  be  done  if  care 
be  taken  to  follow  the  directions  given,  and  never  on  any 
account  to  put  one  wire  round  more  than  one  tooth.  The 
attenij)ted  employment  of  one  long  wire  for  all  the  teeth  by 
some  operators  has  very  injuriously  affected  the  reputation  of 
this  splint  for  firmness  and  solidity,  by  virtue  of  which 
qualities  good  results  can  always  be  obtained. 

Dissimilar  metals  must  not  be  used  in  the  construction  of 
the  frame  and  wires,  owing  to  the  galvanic  action  set  up 
and  unpleasant  taste  produced,  not  to  mention  the  irritation 
to  the  teeth. 

Suture  of  the  jaw  itself  has  been  employed  from  time 
to  time  for  the  treatment  of  both  recent  and  old  fracture, 
and  to  insure  the  union  of  the  two  halves  of  the  bone  after 
its  division  for  removal  of  the  tongue  by  Syme's  method. 
Dr.  Kinloch  of  Charleston  treated,  in  1858,  a  case  of  com- 
pound oblique  fracture  of  unusual  form,  wliich  has  been 
already  referred  to  (p.  9),  by  this  method,  after  other  means 
liad  failed.  "  A  semi-lunar  incision,  about  two  inches  long, 
was  made  upon  the  side  of  the  face,  the  middle  of  the  inci- 
sion reaching  under  the  base  of  the  jaw.  With  Brainard's 
smallest-sized  drill  a  perforation  was  made  through  each 
fragment,  the  drill  being  entered  on  the  outside,  close  to 
the  base  of  the  bone,  and  about  one-eighth  of  an  inch  from 
the  rough  extremity  of  each  fragment,  and  made  to  traverse 
the  bony  tissue  and  the  mucous  membrane  covering  it 
within  the  buccal  cavity.  The  drill  was  afterwards  thrust 
between  the  fragments  and  turned  about,  so  as  to  slightly 
lacerate  the  intermediate  connecting  tissue.  A  stout  silver 
wire  was  then  pa.saed  througli  tliu  perforations  in  the  l)oue, 


THOMAS  S   WIRE- SUTURE. 


39 


from  without  inwards  through  the  posterior  fragment,  and 
in  the  contrary  direction  through  the  anterior  one ;  and 
their  ends  were  tightly  twisted  together,  so  as  to  bring  the 
fragment  into  secure  apposition. 

"  By  the  26th  of  September  good  consolidation  was 
effected,  and  the  suture,  which  had  occasioned  but  little 
suppuration,  was  untwisted  and  removed.  On  the  15tli  of 
October  the  patient  left  the  hospital,  with  the  fistulous 
opening  healed  and  a  good  use  of  the  jaw." — American 
Journal  of  Medical  Sciences,  July  1859. 

Mr.  Hugh  Thomas  of  Liverpool  has  recently  advocated 
the  use  of  the  wire-suture  in  the  treatment  of  recent  frac- 
tures, and  two  of  his  illustrative  cases,  which  had  most 
satisfactory  results,  will  be   found  hi  the   Lancet,   January 


19th,  1867.  This  method  has  been  more  fully  elucidated  in 
a  pamphlet,  and  consists  either  in  drilling  the  fragments  and 
passing  a  copper  wire,  each  end  of  which  is  then  coiled  upon 
a  "  key  "  formed  by  a  steel  rod  with  a  slit  in  it  (fig.  17);  or, 
in  cases  where  the  teeth  are  sound,  in  passing  a  loop  of  wire 
around  the  teeth  on  each  side  of  the  fracture,  and  then 
twiwSting  it  up  with  the  key  (fig.  18).  The  advantage  of  this 
method  is  that  the  wire  can  be  tightened  from  time  to  time, 
as  may  be  required  during  the  treatment,  without  liability 
to  breakage.     I  have  employed  it  in  a  case  of  division  of  the 


40 


TREATMENT  OF  FRACTURED  LOWER  JAW. 


jaw  for  removal  of   the  tongue,  with  advantage ;   and   my 
friend  Mr.  Eushton  Parker  of  Liverpool  speaks  highly  of 


Fig.  18. 


the  method  as  "  the  most  simple  and  effectual  yet  devised." 
One  of  Mr.  Parker's  cases  will  he  found  in  the  Appendix 
(Case  IV.). 

In  the  Lancd,  August  17th,  1867,  Mr.  Wheelliouse 
of  Leeds  has  recommended  the  following  j)lan,  which 
has  proved  successful  in  a  case  of  triple  fracture  (fig.  19), 
but  which  presents  no  great  advantage  over  the  ordinary 
wire : — 

"  Two  silver  pins  were  made  with  fiat,  circular,  and  per- 
forated heads,  each  pin  being  about  an  inch  and  a  quarter 
in  length.  Two  holes  were  bored  with  an  Archimedian 
drill  through  the  substance  of  the  jaw-bone — one  between 
the  roots  of  the  outer  incisor  and  canine  teeth  of  the  un- 
broken side,  and  the  second  between  tlie  roots  of  the  same 
teeth  of  the  fractured  side.  Through  these  holes  the  two 
pins  were  passed  from  hcliind  forwards,  the  perforated  heads 
threaded  with  a  good  stout  silk  ligature,  resting  upon  the 
floor  of  the  mouth  under  cover  of  the  fnenum  of  the  tongue. 
Having  been  well  thrust  forward  through  the  drill-holes, 
the  points  were  bent  in  opposite  directions,  the  loose  frag- 
ment was  placed  in  good  position,  the  ligature  was  brought 


WHEELHOUSE  S    METHOD. 


41 


forward  over  the  teeth,  and  a  figLire-of-8  suture  was  then 
made  round  the  reversed  ends  of  the  pins." 

Fig.  19. 


/ 
According  to  Malgaigne,  Guillaume  de  Salicet  advised 
not  merely  to  tie  the  adjacent  teeth  together,  but  to  fasten 
them  to  those  of  the  upper  jaw.  The  necessity  for  such  a 
contrivance  must  he  very  rare,  but  Dr.  Fountain  success- 
fully treated  a  case  of  double  fracture  and  fracture  of  the 
left  condyle,  which  has  been  already  referred  to  (page  13), 
by  a  somewhat  similar  method.  "  Holes  were  drilled 
through  a  front  incisor  of  each  jaw,  and  a  double  strand 
of  fine  annealed  jeweller's  iron  wire  was  passed  through 
and  twisted  so  as  to  keep  the  parts  in  exact  apposition,  the 
central  fracture,  which  gave  no  troul^le,  being  supported  by 
a  pasteboard  splint.  In  ten  days  the  wires  gave  way,  and 
a  cord  was  inserted  composed  of  four  of  the  same  wires  ;  and 
in  this  way  the  jaw  w\t,s  held  securely  and  immovably  until 
all  the  fractures  were  united — viz.,  four  weeks,  during  which 
time  the  patient  was  noui-ished  l)y  liquids,  wliich  were  easily 


42    TREATMENT  OF  FRACTURED  LOWER  JAW. 

drawn  into  the  mouth  throiigli  the  teetli.  Perfect  union, 
witliout  a  i^article  of  deformity,  took  place,  and  now,  nearly 
four  years  after,  no  one  would  be  able  to  tell  that  any  frac- 
ture had  ever  taken  place. — Neio  York  Journal  of  Medicine, 
January,  1860. 

The  simplest  form  of  apparatus  within  the  mouth  consists 
of  wedges  of  cork,  about  an  inch  and  a  half  long  and  a 
quarter  of  an  inch  in  thickness  at  the  base,  but  sloping 
away  to  a  point,  as  recommended  by  Boyer  and  Miller. 
These  may  be  placed  between  the  molar  teeth,  and,  if  they 
can  be  kept  in  position,  will  maintain  the  regularity  of 
the  teeth'  and  keep  the  incisors  separated  for  the  introduction 
of  food,  a  four-tailed  bandage  being  applied  externally.  My 
own  exj)erience  is  that  the  corks  cannot  be  maintained  in 
position,  and  after  a  few  hours  roll  about  in  the  mouth ;  and 
this  I  find  also  to  have  been  the  experience  of  other  sur- 
geonSj  including  Sir  William  Fergusson,  with  whom  also  I 
fully  agree,  that  the  majority  of  cases  do  well  with  merely 
the  simple  bandage,  not  very  tightly  applied. 

Wedges  of  gutta-percha,  introduced  warm  into  the  mouth, 
so  as  to  become  moulded  to  the  teeth  and  gums,  are  higlily 
recommended  by  Hamilton,  both  as  supports  and,  in  some 
degree,  as  lateral  splints  for  the  fracture.  Miitter's  clamp, 
consisting  merely  of  a  plate  of  silver,  folded  over  the  tops 
and  sides  of  two  or  more  teeth  adjacent  to  the  fracture,  is  a 
contrivance  wliich,  in  its  original  form,  can  have  been  but  of 
little  service,  but  as  modified  by  Mr.  Tomes  and  others  is  a 
very  efficient  method  of  treating  fractures  of  the  body  of  the 
jaw.  Tlie  modification  consists  in  making  the  silver  cap 
fit  accurately  to  tlie  teeth,  for  some  distance  on  each  side 
of  the  fracture,  by  moulding  it  to  a  plaster  cast  of  the  jaw. 
The  caj)  is  then  liued  witli  gutta-i)orcha,  whicli,  being  warmed 
when  the  apparatus  is  applied,  fills  up  interstices  and  fixes 
the  cap,  the  fragments  being  maintained  in  position  whilst 
the  application  is  being  made.  Although  the  assistance  of 
a  dentist  would  be  required  for  tlie  proper  preparation  of 
the  cap,  it  may  not  be  out  of  place  to  notice  the  best  method 
of  obtaining  a  satisfactory  jnodel  u]>on  Avhich   the  cajt  is  to 


METAL    CAPS    FOR  THE    TEETH.  43 

be  formed,  for  which  I  am  indebted  to  Mr.  Tomes.  When 
the  displacement  of  the  fragments  is  great  (as  is  invariably 
the  case  where  such  apparatus  is  required),  it  is  best  to  take 
a  cast  of  the  jaw  in  wax,  without  attempting  to  bring  the 
fragments  into  proper  relation.  Into  this  the  plaster  is 
poured,  and^  when  set,  a  fac- simile  of  the  displaced  fracture 
is  of  course  produced.  By  now  sawing  out  the  piece  of 
plaster  between  the  extremities  of  the  fragments^  these  can 
be  brought  together,  and  a  model  of  the  perfect  jaw  will  be 
produced,  upon  which  the  metal  can  be  carefully  fitted.  When 
all  is  prepared,  by  carefully  adjusting  the  fracture,  the  cap 
will  of  necessity  fit  and  will  maintain  the  fracture  in  its 
normal  position. 

Mr.  Howard  Hayward  has  been  very  successful  in  treating 
cases  of  fracture  of  the  jaw,  of  both  recent  and  old  date,  by 
silver  caps,  fitted  accurately  to  the  teeth  on  each  side  of  the 
fracture,  and   also  over  the  gum  to  the  depth  of  half  an 

Fig.  20. 


inch  in  front  and  a  quarter  of  an  incli  behind  them  (fig.  20.) 
To  the  upper  surface  of  the  plate  two  pieces  of  stout  curved 
wire  are  soldered,  so  as  to  turn  round  the  angles  of  the 
mouth  without  touching  them,  and  these  are  attached  to  a 
simple  gutta-percha  splint;  moulded  externally  to  the  jaw, 
and  retained  in  position  by  an  ordinary  four-tailed  bandage. 
Holes  drilled  in  the  metal  cap,  opposite  the  point  of  fracture, 
permit  of  the  exit  of  any  discharge,  but  this  is  usually  insig- 
nificant in  quantity  when  the  fracture  is  once  properly  set. 
Mr.  Hayward  prefers  metal  to  vulcanite  or  gutta-percha  for 
the  cap,  on  account  of  its  small  bulk,  and  the  consequent 
small  interference  with  the  natural  closure  of  the  mouth — a 
point  of  some  importance,  on  account  of  the  retention  of  the 
saliva. 


44         TREATMENT    OF    FRACTURED    LOWER   JAW. 

Mr.  Barrett,  dental-surgeon  to  the  London  Hospital,  has 
kindly  shown  me  models  of  cases  in  which  he  has  obtained 
most  satisfactory  results,  by  both  metal  and  vulcanite  inter- 
dental splints,  secured  in  the  mouth  by  small  screws  passing 
between  the  necks  of  the  teeth.  One  of  his  cases  was  in  a 
child,  and  here  the  delicate  temporary  teeth  suffered  no 
damage  from  the  screws. 

Mr.  Gunning,  of  New  York  {Nciv  York  Medical  Journal, 
and  British  Journal  of  Dental  l:^ciencc,  1866),  has  contrived  a 
form  of  interdental  splint,,  composed  of  the  vulcanite- rubber 

Fig,  21. 


now  in  common  use  among  dentists,  which  has  yielded  very 
satisfactory  results  in  his  hands,  and  of  which  the  following 
is  a  condensed  description. 

Y\g.  21  represents  the  inner  surface  of  a  splint  which 
incloses  all  the  teeth  and  part  of  the  gum  of  the  lower  jaw, 
and  merely  rests  against  the  upper  teeth  when  the  jaws  are 
closed.  This  s})lint  is  adapted  to  the  treatment  of  all  cases 
which  have  teeth  on  both  sides  of  the  fracture,  except  those 
with  ohstinatc  vertical  dis^jlacement.  The  holes  marked  A 
go  through  tliu  top  of  the  splint,  for  the  purpose  of  syringing 
the  parts  within  witli  warm  water  during  treatment.  The 
dark  round  spots  in  all  tlie  cuts  represent  holes  for  similar 
purposes. 

Mr.  Gunning  lias  generally  used  this  splint  without  any 
fastenings,  but  in  children,  or  even  adults,  it  is  sometimes 
advisable  to  secure  it  by  packthread  wire  screws  passing 
into  or  between  the  tectli,  or  by  the  wings  and  band  of  fig.  24. 

In  cases  with  obstinate  vertical  displacement,  the  sjjlint^ 


gunning's  interdental  splint.s.  45 

in  addition  to  fitting  the  teetli  and  gum  of  the  lower  jaw, 
must    also    inclose  the  upper  teeth,  as   shown   in  fig.    23, 

Fig.  22. 


where  screws   may  be   seen  opposite  both   the  lower   and 
upper  teeth. 

By  this  arrangement  the  fragments  of  the  lower  jaw  are 
secured,  not  only  relatively  to  each  other,  but  also  to  the 
upper  jaw,  B,  is  a  triangular  opening,  of  which  one  side 
corresponds  to  the  cutting  edge  of  the  lateral  incisor, 
which  stood  in  the  end  of  the  fragment  most  displaced  before 
the  splint  was  applied.  C,  an  opening  for  food,  speech,  &c. 
D,  a  channel  for  the  saliva  from  the  parotid  gland  to  enter 
the  mouth,  its  fellow  being  seen  on  the  other  side  of  the 
splint.  E',  a  screw  opposite  the  lower  canine  tooth,  the  head 
of  the  fellow  screw  being  just  discernible.  E,  the  head  of 
a  screw  opposite  the  upper  first  molar  tooth,  the  end  of  its 
fellow  being  seen  on  the  other  side. 

Fig.  23  shows  the  wings  for  cases  having  no  teeth  in  either 
jaw — the  ends  of  the  wings  within  the  mouth  being  imbedded 
in  a  vulcanite  splint  similar  in  principle  to  that  of  Fig.  22. 
F,  upper  wing.  G,  lower  wing.  H,  mental  band  to  hold 
the  jaw  up  to  the  splint.  I,  neck  strap  to  keep  the  band 
back.     K,  balance  strap  to  hold  the  cap  in  place. 

Wings  made  of  steel  may  be  quite  light.  They  should 
have  fine  teeth  along  the  edges  where  the  bands  and  tapes 
bear  to  prevent  slipping,  and  small  holes  every  half-inch  to 
hold  the  strings,  lacing,  &c.     The  arch  of  the  wings  should 


46       treatmp:nt  of  fka(TUBEI)  lower  jaw. 

be  high  enough  to  give  the  lower  lip  room  to  go  well  up. 
The  wiugs  for  each  side  of  the  jaw  are  in  one  piece,  and  the 

Fig.  23. 


parts  within  the  mouth  pass  back  in  tlie  line  of  tlic  upper 
j^uni.  Tlu'V  ai'e  thinned  down  and  ])iercod  with  lioles,  that 
the  rubber  in  wliicli  tluiy  are  imbedded  may  lndd  them 
tirmly. 

The  tape  strings  pass  from  the  cap  inside  and  under  the 
upper  wings,  then  up  between  them  and  the  tape  lacings 
(tig.  23)  which  keep  the  strings  from  slipping,  to  the  cap 
whence  they  started.  The  mental  band  passes  up  between 
the  sides  of  the  lower  jaw  and  the  wings,  where  it  is  tied  by 
the  strings,  which  pass  through  the  holes.  The  band  is 
cut  off  to  show  this  ;  but  when  worn  it  should  be  turned 
down  on  the  outside  and  pinned  just  below  the  wings.  The 
neck  strap  should  be  sewed  to  the  mental  band  on  one  side 
and  pinned  on  the  other,  and  worn  tight  enough  to  keep  the 
band  from  slipping  forward  over  the  chin. 

The  jaw  and  splint  are  supported  by  the  cap  in  front  of 
its  centre.  This  is  counterbalanced  by  the  elastic  strap 
which  passes  from  the  back  of  the  cap  down  around  a  non- 
elastic,  and  much  heavier,  strap,  extending  across  and 
fastened  to  the  shoulders  by  elastic  ends.  The  balance 
strap  returns  to  the  cap,  and  is  buckled  tight  enough  to  hold 
the  jaw  up.      At  night  it  may  be  slackened  to  do  this  with 


gunning's  interdental  splints.  47 

the  neck  flexed.     It  slides  on  the  shoulder  strap  as  tlie  head 
inclines  to  either  side. 

In  order  to  meet  the  case  of  practitioners  out  of  reach 
of  a  dentist,  Mr.  Gunning  has  suggested  a  splint  made  of 
tin  and  lined  with  gutta-percha  (fig.  24)  very  much  resenir 
Lling  Mr.  Hayward's  metal  cap.      Six  or  eight  sizes  are  to 

Fig.  24. 


be  cast  and  kept  ready  for  use,  from  which  one  could  be 
selected  suitable  for  the  jaw.  The  wings  are  of  malleable 
iron,  tinned  to  prevent  rusting  and  for  more  readily  solder- 
ing.    Three  sizes  would  probably  be  sufficient  to  select  from. 

The  splint  should  have  a  handle  in  front  that  it  may  be 
used  as  a  cup  to  take  the  impression  of  the  jaw — the  holes 
being  useful  to  allow  a  small  probe  to  be  pressed  through 
the  wax  down  to  the  teeth,  thus  allowing  air  to  enter  to 
facilitate  the  removal  of  the  impression,  and  when  in  use  as 
a  splint  giving  entrance  to  warm  water,  thrown  from  a 
syringe,  to  keep  the  parts  clean. 

The  splint  should  be  made  to  fit  well  by  bending,  cutting 
off  the  edges  and  rounding  them  smoothly.  When  a 
tooth  projects  so  as  to  keep  the  splint  from  fitting,  a  hole 
may  be  cut  to  let  the  tooth  through,  if  the  metal  cannot  be 
hammered  out.  This  should  all  be  done  before  taking  the 
impression,  as  a  well-fitted  cup  assists  greatly  in  this  im- 
portant matter. 

(The  adaptability  of  this  splint  is  shown  in  the  fact  that 
the  one  from  which  the  cut  was  taken  had  been   used  sue- 


48         TREATMENT    01'    FRACTURED    LOWER   JAW. 

cessfully  on  two  different  jaws,  so  unlike  that  the  first  was 
a  quarter  of  an  inch  wider,  where  the  ends  of  the  splints 
rested,  than  the  second.  Wlien  fitting  it  to  the  second  jaw, 
it  was  necessary  to  cut  off  a  part  of  the  riglit  wing,  to  keep 
it  clear  of  tlie  corner  of  the  mouth.  This  accounts  for  the 
difference  in  the  width  of  the  arches  as  seen  in  the  cut. 
The  indentations  on  the  top  of  the  splints  were  made  by 
the  boys  in  eating.) 

One  of  Mr.  Gunning's  successful  cases  was  particularly 
interesting  from  the  important  political  position  of  the 
patient,  no  less  than  the  serious  nature  of  the  injuries, 
received  at  the  hands  of  a  would-be  assassin. 

Mr.  J.  B,  Bean  of  Atlanta,  Georgia,  appears  to  have 
employed  a  vulcanite  interdental  splint  very  similar  to  Mr. 

Fig.  25. 


Gunning's,  but  with  the  addition  of  a  mental  compress,  with 
great  success  among  the  wounded  soldiers  of  the  Confederate 
army,  and  his  apparatus  is  very  favourably  reported  upon  by 
Inspector-General  Covey,  {liichmond  Medical  Journal,  and 
British  Jovrnal  of  Dental  Science,  1866.)  Hamilton  also 
speaks  well  of  the  apparatus  in  the  fourth  edition  of  his 
work  on  "  Fractures,"  and  gives  an  illustration,  from  A\hich 
the  accompanying  drawing  (fig.  25)  is  taken. 


bean's  apparatus.  49 

Ur.  Covey  writes  : — "  The  adjustment  of  the  splint  to  the 
fracture  is  very  simple.  It  is  inserted  into  the  mouth  of 
the  patient ;  the  fragments  drawn  forward,  and  the  teeth 
adjusted  to  their  corresponding  indentations.  The  jaws  are 
then  closed  and  held  firmly  in  position  by  the  application 
of  the  mental  compress  and  occipito-frontal  bandage ;  this 
prevents  any  displacement  of  the  splint  or  motion  of  the 
jaws. 

The  mental  compress  is  designed  for  retaining  the  teeth 
in  their  indentations  of  the  splint,  by  upward  pressure  ap- 
plied to  the  base  of  the  mental  process,  counteracting  thus 
the  traction  of  those  muscles  which  most  tend  to  cause  dis- 
placement. There  is  an  advantage  also  in  relieving  the 
parts  from  the  lateral  pressure  produced  by  the  four-tailed 
bandage  or  double-cross  roller  bandage,  generally  applied 
to  these  cases. 

The  compress  is  composed  of  a  light  piece  of  wood, 
which  is  four  and  a  half  inches  in  length,  three-sixteenths 
of  an  inch  in  thickness,  and  one  inch  and  a  half  in  width 
in  the  middle,  tapering  to  seven-eighths  of  an  inch,  and 
round  at  the  ends ;  to  each  of  which  is  attached  a  metallic 
side-piece  four  or  five  inches  in  length,  and  from  three- 
quarters  to  one  inch  in  width ;  also  a  shallow  cup  fitting 
the  apex  of  the  chin.  Encasing  these  side  pieces  are  the 
temporal  straps  made  of  stout  cloth,  and  secured  by  a  strong 
cord  at  the  base  of  each  piece. 

The  occipito-frontal  bandage  is  composed  of  a  band  pass- 
ing around  the  head,  from  the  forehead  to  the  occipital 
protuberance  behind,  and  secured  by  a  buckle  one  inch  to 
the  right  of  the  median  line  behind ;  of  another  strap 
secured  to  the  band  in  front  and  behind  ;  and  a  third  strap 
extending  from  the  temporal  buckles  on  either  side,  and 
secured  to  the  middle  strap  at  the  point  of  crossing." 

A  combination  of  external  and  internal  splints  was  invented 
by  Eutenick,  a  German  surgeon,  in  1799,  and  improved  by 
Kluge.  It  is  thus  described  by  Dr.  Chester  {Medico-Chirurgical 
Review,  vol.  xx.  p.  471) : — "  It  consists,  1st,  of  small  silver 
grooves,  varying  in  size  according  as  they  are  to  be   placed 

E 


50   TREATMENT  OF  FRACTURED  LOWER  JAW. 

on  the  incisors  or  molars,  and  long  enough  to  extend  over 
the  crowns  of  four  teeth  ;  2nd,  of  a  small  piece  of  board, 
adapted  to  the  lower  surface  of  the  jaw,  and  in  shape  re- 
sembling a  horse-shoe,  having  at  each  horn  two  holes,  one 
on  either  side;  3rd,  of  steel  hooks  of  various  sizes,  each 
having  at  one  extremity  an  arch  for  the  reception  of  the 
lower  lip,  and  another,  smaller,  for  securing  it  over  the  silver 
channels  on  the  teeth,  and  at  the  other  end  a  screw  to  pass 
through  the  horse-shoe  splint,  and  to  be  secured  to  it  by  a 
nut  and  a  horizontal  branch  at  its  lower  surface ;  4th,  of  a 
cap  or  silk  nightcap  to  remain  on  the  head ;  and  5th, 
of  a  compress  corresponding  in  shape  and  size  with  the 
splint.  The  net  or  cap  having  been  placed  on  the  head  and 
the  two  straps  fastened  to  it  on  each  side,  one  immediately 
in  front  of  the  ear  and  the  other  about  three  inches  farther 
back,  which  are  to  retain  the  splint  in  its  position  by  pass- 
ins  through  the  two  holes  in  each  horn ;  a  silver  channel  is 
placed  on  the  four  teeth  nearest  to  the  fracture,  on  this  the 
small  arch  of  the  hook  is  placed,  and  the  screw  end  having 
been  passed  through  a  hole  in  the  splint,  is  screwed  firmly 
to  it  by  a  nut,  after  a  compress  has  been  placed  between 
the  splint  and  the  integuments  below  the  jaw.  If  there 
is  a  double  fracture,  two  channels  and  two  hooks  must  of 
course  be  used." 

Bush  invented  a  similar  apparatus  in  182.2,  and  Houzelot 
in  1826 ;  since  which  the  apparatus  has  been  variously 
modified  by  Jousset,  Lonsdale,  Malgaigne,  and  perhaps 
others. 

Lonsdale's  apparatus,  as  Mr.  Berkeley  Hill  remarks 
{British  Medical  Journal,  March  2,  1867),  "  is  only  suited 
to  cases  of  fracture  between  the  incisors,  as  its  ivory  cap  is 
too  short  to  reach  far  along  the  arch  of  the  teeth.  It  is 
also  very  cumbrous ;  and  causes  great  pain  by  the  pressure 
under  the  chin  necessary  to  keep  the  fragment  in  place,  and 
by  the  jogging  of  the  vertical  part  against  the  sternum." 

Fig.  26  shows  tliis  apparatus  somewhat  modified  by 
Mr  Hill,  to  whom  I  am  indebted  for  tlie  illustrations.  In 
the   ordinary  Lonsdale's   apparatus,   the  rod    carrying   the 


Lonsdale's  apparatus.  51 

ivory  cap  (a)  for  the  incisors  slides  freely  up  and  down  a 
bar  projecting  downwards  from  the  chin-piece  (b),  and, 
when  in  the  required  position,  is  fixed  by  a  pin.  Mr.  Hill 
has  had  a  screw  thread  cut  on  the  bar,  on  which  a  nut  {^ 

Fig.  26. 


travels  so  as  to  force  down  the  rod  carrying  the  cap  (a), 
and  thereby  approximate  the  cap  on  the  incisors  to  the 
chin-piece. 

When  this  apparatus  is  to  be  applied,  the  fragments  are 
placed  in  position  by  the  hands,  the  ivory  cap  set  on  the 
incisors,  and  the  chin-piece,  which  should  be  well  padded 
with  lint  or  wool  stitched  in  wash-leather,  brought  up  into 
place  under  the  jaw,  and  the  two  made  fast.  The  two  cheek- 
pieces  are  then  adjusted  so  as  to  press  lightly  on  the  jaw  at 
each  side,  to  prevent  the  apparatus  from  swaying  aside  out 
of  place ;  and  a  tape  is  fastened  to  a  hole  at  each  end  of  the 
horse-shoe,  and  carried  behind  the  neck,  to  keep  the  instru- 
ment from  slipping  forwards.  So  applied,  Lonsdale's  appa- 
ratus permits  opening  of  the  mouth  for  eating  and  speaking; 
and,  if  the  fracture  be  single  and  between  the  incisors,  it 
keeps  the  fragments  in  position  very  fairly. 

Fig.  27  represents  the  modification  of  Lonsdale's  splint, 
contrived  by  Mr.  Berkeley  Hill,  for  the  treatment  of  a  com- 
plicated case  of  double  fracture  in  University  College  Hos- 

1  2 


52 


TREATMENT   OF   FRACTURED   LOWER    JAW.' 


pital  in  1866,  the  ivory  cap  of  the  incisors  being  replaced 
by  a  metal  mould  of  the  alveolar  arch,  and  the  lateral  pads 
removed. 


Fig.  27. 


Mr.  Moon,  of  Guy's  Hospital,  has  devised  another  modifi- 
cation of  Lonsdale's  splint,  which  has  the  advantage  of  being 
made  in  two  halves  (fig.  28  B  B.)  so  as  to  fit  any  jaw  exter- 


FiG.  28. 


Fig.  29. 


nally.  The  metal  cap  for  the  teeth  (fig.  29)  is  kept  in  place 
by  horizontal  l)ars  passing  at  the  angles  of  the  mouth,  or  may 
be  used  separately  by  being  secured  with  wires. 

The  great  difficulty  in  using  all  forms  of  rigid  splints  to  the 


TREATMENT    OF  UNUNITED    FRACTURE.  53 

jaw  is  the  tendency  of  tlie  support  for  tlie  chin  to  produce 
abscess  and  ulceration  by  pressing  upon  the  sharp  border  of 
the  bone  ;  and  the  cases  in  which  a  simple  metallic  interdental 
splint  would  not  effect  a  cure  must  be  rare. 

The  treatment  of  fracture  of  the  neck  of  the  lower  jaw,  in 
those  rare  cases  where  the  patient  survives  the  injury  and 
the  nature  of  the  accident  is  recognised,  is  sufficiently  simple 
when  there  is  no  displacement,  since  the  ordinary  bandage 
will  in  most  cases  suffice.  When,  however,  the  condyle  is 
displaced  by  the  action  of  the  pterygoideus  externus,  reduc- 
tion must  be  effected  as  recommended  by  Eibes,  by  drawing 
the  jaw  horizontally  forwards,  and  at  the  same  time  pushing 
the  condyle  outwards  with  the  finger  introduced  far  back 
into  the  mouth.  Reduction  being  accomplished,  the  jaw 
must  be  pressed  upwards  and  backwards  to  fix  the  condyle 
in  the  glenoid  cavity,  after  which  a  bandage  may  be  applied. 

Gross  says  the  best  means  to  counteract  the  tendency  of 
the  external  pterygoid  to  produce  displacement  is  "  to  confine 
a  thick  graduated  compress  behind  the  angle  of  the  bone, 
the  treatment  being  in  other  respects  the  same  as  in  fracture 
of  the  body  of  the  jaw."     (Gross's  "  Surgery,"  p.  967). 

Tlie  Treatment  of  Ununited  Fracture  of  the  Jaw. — The 
causes  of  non-union  of  a  fractured  jaw  have  been  described 
in  a  ]3revious  section.  When  the  delay  is  due  to  a  superficial 
necrosis,  time  for  exfoliation  to  take  place  is  allthat  is  re- 
quired ;  when,  however,  the  necrosis  is  extensive,  or  the  loss 
of  substance  great,  it  is  not  desirable  to  produce  union 
between  the  fragments,  since  thereby  an  unsightly  deformity 
will  be  induced,  which  can  be  avoided  by  the  use  of  apparatus 
to  retain  the  parts  in  their  normal  relation.  This  subject 
will  be  referred  to  more  particularly  under  the  head  of 
"  Gunshot  Injuries." 

Dupuytren,  in  1818^  treated  a  case  of  ununited  fracture, 
the  result  of  a  gunshot  injury,  in  the  person  of  a  Russian 
officer  {vide  p.  32),  three  years  after  the  receipt  of  the  injury, 
by  resecting  the  extremity  of  one  fragment  and  rasping  the 
other.  In  order  to  maintain  the  fragments  in  position  the 
dentist  Lemaire  was  called   in,  and   devised  the  following 


54    TREATMENT  OF  FHACTURED  LOWER  JAW. 

plan,  the  fracture  being  on  the  right  side  of  the  jaw : — 
"  First,  to  carry  the  posterior  fragment  inward,  he  united 
by  means  of  a  platinum  wire  the  wisdom  tooth  in  this  frag- 
ment to  one  of  the  bicusi^ids  of  the  other  side ;  then,  to 
carry  the  anterior  fragment  forward  and  lessen  the  over- 
lapping as  much  as  possible,  a  second  wire  was  stretched 
from  the  first  lower  bicuspid  on  the  right  side  to  the  first 
upper  bicuspid  on  the  left ;  and  a  third  bound  together  the 
two  canine  teeth  on  the  left  side."  (Vide  Malgaigne,  and 
for  the  entire  case  Dupuytren^s  Legons  Ondcs,  vol.  iv.)  A 
cure  was  accomplished  at  the  end  of  two  months,  but  one 
of  tlie  wires  had  nearly  bisected  the  tongue  ;  and  as  it  had 
gradually  become  embedded  the  flesh  had  closed  over  it,  and 
it  had  to  be  cut  and  withdrawn. 

Dr.  Physick  in  1822  treated  a  case,  two  years  after  the 
receipt  of  the  injury,  by  the  introduction  of  a  seton  between 
the  ends  of  the  Ijones.  This  Avas  left  in  situ  for  three 
months,  and  induced  suppuration  and  the  discharge  of  frag- 
ments of  necrosed  bone,  with  an  ultimate  cure.  (Fhila- 
delpliia  Journal  of  Medical  and  Physical  Sciences,  vol.  v. 
p.  116.) 

Suture  of  the  fragments  of  bone  would  appear  to  offer 
the  readiest  means  for  keeping  the  two  portions  in  appo- 
sition, and  this  plan  has  been  successfully  carried  into  exe- 
cution by  Mr.  Bickersteth,  of  LiveriDool,  who,  in  his  paper 
read  before  the  Medico- Chirurgical  Society  in  1864,  nar- 
rated two  cases  in  which  he  had  succeeded  in  producing 
union  by  fastening  the  two  fragments  together  by  means  of 
a  drill,  or  some  similar  contrivance. 

The  first  case  was  a  fracture  of  the  losver  jaw,  in  which 
the  bones  had  united  in  such  a  position  as  to  render  the 
patient  a  most  unsightly  object.  As  the  incision  that  would 
have  been  necessary  in  this  instance  for  the  purpose  both 
of  putting  the  bone  into  proper  position  and  removing 
deformity  of  the  soft  parts,  would  not  have  allowed  the  use 
of  external  splints  or  supports ;  and  as  it  was  found  imprac- 
ticable to  effect  this  object  by  fixing  the  teeth  by  an  aj^pli- 
ance  within  the  mouth,  it  was  absolutely  necessary   that 


TREATMENT    OF    UNUNITED    FRACTURE.  55 

some  means  should  be  devised  by  which  the  divided  portions 
of  the  jaw  could  be  securely  fixed.  It  occurred  to  Mr. 
Bickersteth  that  jDegs  or  nails  would  answer  the  purpose, 
especially  as  he  had  already  observed  their  presence  caused 
so  little  inconvenience.  Accordingly,  at  the  operation  the 
apposition  of  the  fractured  portions  was  secured  by  means 
of  tw^o  round-headed  nails.  They  most  effectually  answered 
their  purpose,  and  no  external  splint  or  bandage  was  re- 
quired. The  case  did  well,  no  undue  action  being  set  up. 
On  the  twenty-second  day  after  the  operation  one  of  the 
nails  came  away.  The  patient  left  the  infirmary  perfectly 
well,  the  jaw  being  firmly  united  in  its  proper  position,  and 
the  deformity  of  the  soft  parts  removed.  One  of  the  nails 
remained  in,  and  the  last  accounts  state  that  its  presence 
caused  no  inconvenience.  The  second  case  recorded  was 
one  that  presented  many  points  in  common  with  the  one  just 
narrated.  No  external  incision  was  made,  and  ordinary 
drill-heads  were  substituted  for  nails.  The  result  was  every- 
thing that  the  operator  could  have  wished. 

Dr.  Cooper,  of  San  Francisco,  treated  successfully  an  un- 
united fracture  of  the  lower  jaw  by  silver  sutures.  In  the 
report  of  the  case  the  exact  seat  of  the  fracture  is  not  given, 
but  it  was  evidently  in  the  body  of  the  bone.  The  peri- 
osteum was  dissected  up,  the  ends  of  the  bone  bared,  after 
which  they  were  carefully  united,  and  the  case  did  well. 
{Philaddijhia  Medical  and  Surgical  Reporter^  1863,  and 
Medical  Circular,  July  23,  1862.) 


56 


CHAPTEE  IV. 

FKACTUEE    OF    THE    UPPEE    JAW. 

Feactures  of  the  upper  jaw  are  not  nearly  so  common  as 
those  of  the  lower,  though  their  results  are  often  more 
serious,  owing  to  the  great  violence  necessarily  undergone. 
As  in  the  lower  jaw,  fractures  of  the  alveolus  may  result 
from  the  extraction  of  teeth,  and  particularly  from  the  use 
of  the  "  key ;"  and  so  well  ascertained  was  this  fact,  that 
in  former  days  even,  when  the  key  was  recommended  and 
employed  extensively,  Mr.  Thomas  Bell  ("  On  the  Teeth/' 
p.  301)  proscribed  its  use  in  extracting  the  upper  wisdom 
teeth  on  account  of  the  danger  of  producing  fracture  of  the 
tuberosity  of  the  maxilla,  against  which  the  fulcrum  would 
rest.  A  fracture  thus  produced  may  extend  to  the  palatine 
process,  and  even  to  the  palate  bone,  and  might,  if  extensive, 
give  rise  to  necrosis  and  subsequent  exfoliation  of  large 
portions  of  bone. 

Fractures  of  the  upper  jaw  may  be  produced  indirectly 
by  falls  on  the  face  ;  thus  Listen  ("  Practical  Surgery,"  p.  55) 
narrates  the  case  of  a  man  who,  slipping  on  a  slide  in  the 
street,  fell  and  struck  the  malar  bone  of  the  left  side  ;  he 
had  sustained  a  vertical  fracture  through  the  orbitar  process 
of  the  superior  maxilla. 

'Direct  blows  upon  the  bone  itself  are,  however,  the  most 
frequent  causes  of  fracture,  and  these,  from  the  nature  of  the 
injury,  are  often  comjDOund. 

Mr.  James  Salter  has  recorded  a  case  {Lancet,  June  16, 
1860)  of  a  young  gentleman  who  sustained  fracture  of  the 
upper  jaw  from  violent  contact  with  a  fellow-cricketer's 
forehead.  Here  fortunately  none  of  the  incisor  teeth  were 
knocked  out,  as  so  frequently  happens  in  accidents  of  the 


FRACTURE   OF   THE   UPPER   JAW. 


57 


kind ;  but  a  fracture  of  the  bone  was  produced  immediately 
behind  the  right  canine  tooth,  which  extended  backwards  so 


Fig.  30. 


Drawing  from  the  plaster  cast  of  the  upper  jaw,  inverteii. 
Fig.  31. 


Illustration  of  the  gold  plate  or  splint ;  a,  h,  and  c  corresponding  to 
the  first  and  second  pre-molars  and  first  molar  respectively. 

as  to  inchide  the  alveoli  of  the  bicuspids  and  first  molar 
teeth,  which  were  driven  inwards  towards  the  median  line, 
to  the  extent  of  about  one-third  of  an  inch,  as  seen  in  the 
drawing  (fig.  30).  There  was  a  corresponding  depression  on 
the  outer  side  of  the  jaw,  and  this  was  somewhat  apparent 
also  on  the  face.  Yery  little  swelling  followed  the  injury, 
and  there  was  not  much  pain  except  on  manipulation.  The 
principal  inconvenience  was  due  to  the  want  of  proper 
apposition  of  the  teeth  of  the  two  jaws,  and  the  mouth  con- 
sequently could  not  be  closed  satisfactorily.     On  endeavour- 


58  FRACTURE    OF   THE   UPPER   JAW. 

ing  to  force  the  displaced  bone  into  its  proper  situation, 
considerable  pain  was  produced  ;  it  could  not  be  completely 
reduced,  and  resumed  its  former  position  as  soon  as  pressure 
was  withdrawn.  Distinct  crepitus  was  felt  during  this 
manipulation. 

Mr.  Salter  succeeded  in  overcoming  the  tendency  of  the 
fragments  to  displacement  by  the  adaptation  of  a  gold  plate 
(fig.  31)  to  it  and  to  the  adjacent  teeth,  and  a  complete  cure 
was  the  result. 

The  kick  of  a  horse  often  inflicts  most  serious  injuries 
upon  the  upper  jaw,  and  of   this  the  classical  case  recorded 
by  Eichard  Wiseman,  in  his  "  Chirurgical  Treatise"  (1794), 
is  a  good  example.  Here  a  boy,  eight  years  old,  received  such 
a  blow  on  the  middle  of  his  face,  that  he-  appeared  at  first 
dead,  and  afterwards  lay  in  a  prolonged  coma.     "  When  I 
first   saw   him,"    says  Wiseman^  "  he   presented  a   strange 
aspect,  having  his  face  driven  in,  his  lower  jaw  projecting 
forward ;  I  knew  not  where  to  find  any  purchase,  or  how 
to  make  any  extension.  But  after  a  time  he  became  sensible, 
and  was  persuaded  to  open  his  mouth.    I  saw  then  that  the 
bones  of  the  palate  were  driven  so  far  back  that  it  was  im- 
possible to  pass  my  finger  behind  them,  as  I  had  intended, 
and  the  extension  could  be  made  in  no  other  way.     I  ex- 
temporized an  instrument,  curved  at  its  extremity,  which  I 
engaged  behind  the  palate,  and  having  carried  it  a  little 
upward  used  it  to  draw  the  bone  forward,  which  I  did  with- 
out any  difficulty ;  but  I  had  hardly  withdrawn  the  instru- 
ment when  the  fractured    portions    went    back    again.     I 
then  contented  myself  with  dressing  the  face  with  an  astrin- 
gent cerate  to  prevent  the  affiux  of  the  humours  ;  I  likewise 
prescribed  bleeding ;  and  some  hours  afterwards  I  had  an 
instrument  better  constructed  to  reduce  the  large  mass  of 
displaced  bone  to  its  proper  position.     I  had  it  held  by  the 
child's  hand,  by  that  of  its  mother,  or  of  an  assistant,  each 
for  a  certain  time.     Nothing  else  was  done.     Thus  by  our 
united  attention  the  tonicity  of  the  parts  was  maintained ; 
the  callus  was  developed,  and  in  proportion  as  it  became 
solidified  the  parts  became  stronger,  the  face  assumed  a  good 


INJURY   TO    FACIAL  BONES.  59 

appearance,  certainly  better  than  could  have  been  hoped  for 
after  such  marked  displacement,  and  the  child  was  entirely 
cured." 

The  most  frightful  injury  to  the  face  (except  from  gun- 
shot wounds)  I  ever  witnessed,  was  from  the  passage  of  a 
waggon  wheel  over  the  face  of  a  man  who  fell  in  the  street. 
Here  the  bones  were  completely  shattered,  and  the  maxilhe 
were  torn  from  one  another,  and  death  was  instantaneous. 
A  cast  of  this  frightful  deformity  is  in  the  museum  of  the 
Westminster  Hospital. 

A  case  very  nearly  as  desperate  at  first,  but  which  fortu- 
nately recovered,  was  admitted  into  the  same  hospital  in 
1860,  and  resulted  from  the  overturn  of  a  cab  upon  the  face 
of  its  fare,  who  at  the  moment  was  leaning  out  of  window 
to  direct  the  driver.  Here,  in  addition  to  a  fracture  of  the 
lower  jaw  a  little  to  the  left  of  the  median  line,  there  were 
two  fractures  of  the  superior  maxilla,  about  an  inch  on 
either  side  of  the  median  line ;  the  nasal  bones  were  broken; 
both  malar  bones  were  loose  and  separated  from  their  at- 
tachments, and  the  left  bone  was  fractured,  as  also  the 
external  angular  process  of  the  frontal  bone.  Though  not 
positively  ascertained,  the  vomer  was  no  doubt  fractured, 
and  probably  the  vertical  plate  of  the  ethmoid  too.  In  Dr. 
Fyffe's  report  of  the  case  {Lancet,  July  18,  1860),  which  I 
can  confirm  by  personal  observation,  it  is  well  noticed, — "  It 
was  remarkable  to  observe  how  movable  the  bones  of  the 
face  were.  On  watching  the  patient's  profile  whilst  he  was 
in  the  act  of  swallowing  food,  the  whole  of  the  bones  of  the 
face  were  observed  to  move  up  and  down  upon  the  fixed  part 
of  the  skull  as  the  different  parts  were  brought  into  motion ; 
it  appeared  as  if  the  integuments  only  retained  them  in  their 
position.  It  was  a  curious  featm^e  in  the  case  that  notwith- 
standing the  very  extensive  injury  done,  and  the  violent 
character  of  the  force  which  caused  them,  not  a  single  tooth 
was  fractured  or  misplaced."  This  patient  made  a  perfect 
recovery,  and  his  treatment  will  be  alluded  to  under  another 
section. 

Fracture  of  the  upper  jaw  extending  into  the  antrum  may 


60  FEACTURE   OF   THE  UPPER   JAW. 

give  rise  to  subsequent  suppuration  in  tliat  cavity,  as 
remarked  by  Listen,  but  this  is  by  no  means  a  necessary 
consequence.  A  remarkable  case  of  transverse  fracture  of 
the  upper  jaw  which  communicated  with  the  nose  and  with 
both  antra  was  recently  under  Mr.  Hutchinson's  care  in  the 
London  Hospital,  in  which  perfect  recovery  took  place  with- 
out exfoliation  of  any  part  of  the  bone,  although  the  alveolus 
containing  all  the  teeth  was  completely  separated  and 
depressed  about  half  an  inch.  Here  the  injury  was  the 
result  of  a  "  jam"  between  a  "  lift"  and  a  cross  bar. 
{Medical  Circular,  February,  1867.)  A  very  similar  case 
occurred  to  Dr.  Guentha,  when  a  workman  was  struck  in  the 
face  by  the  angle  of  a  large  mass  of  stone.  Here  there  was 
complete  separation  of  the  alveolar  process  of  the  upper  jaw, 
the  entire  arch  in  an  unbroken  state  lying  on  the  lower  jaw, 
only  suspended  by  some  shreds  of  the  gum  and  soft  palate. 
This  man  also  made  a  perfect  recovery.  {British  and  Foreign 
Quarterly  Eevieio,  October,  1860.)  In  the  summer  of  1871 
two  patients  were  admitted  into  University  College  Hospital 
within  a  few  hours  of  each  other,  in  both  of  whom  the  superior 
maxillae  were  fractured  and  freely  movable.  In  one  case 
perfect  recovery  ensued,  and  death  in  the  other,  the  post- 
mortem examination  proving  that  there  was  no  injury  to  the 
base  of  the  skull. 

In  cases  such  as  these,  when  there  is  obvious  displace- 
ment there  can  be  no  difficulty  in  the  diagnosis  of  the 
fracture,  but  cases  have  no  doubt  frequently  occurred  where 
a  fracture  without  displacement  has  been  overlooked.  Dr. 
A.  Guerin  has  elaborately  investigated  this  subject  {Archives 
Gendrcdes  de  Medccine,  July,  1866),  and  has  shown  from  a 
preparation  taken  from  a  fatal  •  case  and  from  experiments 
upon  the  dead  body,  that  violent  blows  below  the  orbits 
fracture  not  only  the  maxillary  bones,  but  that  the  fracture 
usually  extends  to  the  vertical  portion  of  the  palate  bone 
and  the  pterygoid  process  of  the  sphenoid,  without  producing 
the  slightest  displacement.  The  diagnosis  of  the  injury 
cannot  be  established  by  any  external  manipulation,  but  liy 
carrying  the  linger  into  the  mouth  and  pressing  against  the 


COMPLICATIONS  OF    FRACTURE.  G 

internal  pterygoid  plate,  pain  will  be  produced  and  mobility 
of  the  process  will  be  ascertained.  The  diagnosis  was  con- 
firmed in  one  of  Dr.  Giierin's  cases  which  recovered,  by  an 
ecchymosis  beneath  the  mucous  membrane  of  the  palate.  In 
his  fatal  case  he  found  fracture  of  the  vertical  plate  of  the 
ethmoid,  in  addition  to  the  other  injuries. 

The  nasal  process  of  the  superior  maxilla  has  been  frac- 
tured  by  blows  which  have  also  driven  in  the  nasal  bone, 
and  in  these  cases  emphysema  of  the  cellular  tissue  of  the 
face  is  not  uncommon,  and  is  best  checked  by  the  application 
of  collodion.  A  complication  of  this  form  of  fracture  which 
has  been  met  with,  is  permanent  obstruction  of  the  nasal  duct, 
leading  to  subsequent  troublesome  epiphora,  of  which  I  have 
seen  an  instance. 

Separation  of  the  two  maxillse  in  the  median  suture  has 
been  seen  in  cases  of  fatal  injury  to  the  face,  &c.,  on  many 
occasions,  but  Malgaigne  gives  a  case  of  the  kmd  where  the 
patient  recovered.  The  patient,  a  man  aged  twenty-one, 
owing  to  a  fall  from  a  height  sustained,  in  addition  to  other 
injuries,  "a  separation  of  the  upper  maxillary  and  palate 
bones  in  their  median  suture  to  the  extent  of  nine  milli- 
metres, with  depression  of  the  entire  left  side  of  the  face 
without  any  alteration  of  the  soft  parts."  The  jD^^i'ts  came 
together  spontaneously,  and  the  patient  recovered  without 
deformity. 

Hamilton,  however,  quotes  (p.  10.2)  a  case  from  Harris, 
of  New  York,  in  which  a  child,  two  years  of  age,  had  separa- 
tion of  the  maxillary  and  palate  bones  in  the  median  line, 
the  separation  being  sufficient  to  admit  the  little  finger,  and 
here  the  bones  were  still  open  six  weeks  after  the  accident. 

Comijlications. — The  teeth  of  the  upj^er  jaw  may  be  broken 
or  dislocated,  as  in  the  case  of  fracture  of  the  lower  jaw ; 
but  if  merely  loosened,  should  never  be  removed,  since 
they  will  probably  become  again  firmly  attached. 

Splintering  of  the  bone  is  much  more  common  in  the 
upper  than  the  lower  jaw,  particularly  after  gunshot  in- 
juries, and  here  modern  experience  has  shown  the  advisa- 
bility of  leaving  the  fragments  to  become  consolidated,  as 


62  FRACTURE   OF    THE   UPPER   JAW. 

tliey  almost  invariably  do,  and  the  non-necessity  for  the 
performance  of  dangerous  operations  of  resection  of  the 
fragments — a  subject  which  will  be  again  referred  to. 

Hc^emorrhage  is  much  more  frequent  and  copious  in  frac- 
tures of  the  upper  than  in  those  of  the  lower  jaw,  as  might 
be  anticipated  from  the  greater  vascularity  of  the  part.  A 
case  of  fracture  of  both  upper  and  lower  jaws,  where  pro- 
fuse haemorrhage  was  caused  by  division  of  the  facial  artery, 
has  been  already  referred  to,  but  the  haemorrhage  not  un- 
frecjuently  conies  from  the  internal  maxillary  vessel  and  may 
be  immediately  fatal.  Secondary  heemorrhage  in  case  of 
severe  injury  to  the  upper  jaw  is  by  no  means  uncommon, 
and  according  to  the  Surgeon-General  of  the  American 
Army  (Circular  No.  6,  Washington,  November  1,  1865,)  was 
the  principal  source  of  fatality  in  these  cases,  ligature  of  the 
carotid  artery  having  been  frequently  performed  with  the 
result  of  only  postponing  for  a  time  the  fatal  event. 

Ncrvons  Affections. — Injury  to  the  infra-orbital  nerve 
and  its  branches  must  necessarily  ensue  in  cases  of  severe 
fracture  and  comminution  of  the  superior  maxilla,  and  con- 
sequent numbness  or  modification  of  sensation  will  be  the 
result.  A  lady,  recently  under  my  care,  who  fell  down  a 
flight  of  stairs  and  sustained  severe  injuries  to  the  head  and 
face,  although  no  fracan^e  of  the  jaw  could  be  detected, 
suffers  from  partial  anaesthesia  and  a  pricking  sensation  in 
the  skin  below  the  orbit.  Robert  mentions  {Gazette  tics 
Hointaux,  1859,  p.  157)  the  case  of  a  woman  who  was  run 
over  and  sustained  a  fracture  with  permanent  paralysis  of 
the  infra-orbital  nerve.  Serious  brain  symptoms  may  ensue 
when  the  fracture  runs  back  to  the  sphenoid  bone  as  de- 
scribed by  M.  Gucrin  (p.  60),  since  the  fissure  may  extend 
to  the  cranium,  and  this  is  especially  likely  to  happen  when 
the  whole  of  the  septum  narium.is  driven  back  with  the 
jaws. 

Treatment  of  Fracture  of  the  U'^rper  Jav\ — Fractures  of 
the  upper  jaw  require  but  little  treatment  compared  with 
those  of  the  lower  jaw,  since  the  part  is  naturally  so  mucli 
more  fixed  that  there  is  little  difficulty  in  keeping  the  frag- 


TREATM.EN£  OK    fflACTUilE   OF    UPrER  JAW.       63 

rnents  in  position.  The  lia3morrliage,  wliicli  is  often  free, 
must  be  arrested  by  cold,  the  application  of  ^styptics,  and,  as 
a  last  resource,  the  actual  cautery.  The  operation  of  deli- 
gation  of  the  carotid  artery  in  these  cases  has  yielded  such 
unsatisfactory  results  as  to  render  the  surgeon  unwilling  to 
resort  to  it  except  under  the  most  desperate  circumstances, 
and  he  would  in  my  opinion  be  justified  in  laying  open  the 
face  and  removing  large  fragments  of  bone  so  as  to  apply 
the  cautery  more  satisfactorily,  rather  than  resort  to  a  dan- 
gerous and  doubtful  operation.  When,  as  is  most  commonly 
the  case,  the  soft  tissues  of  the  face  are  lacerated  and  the 
haemorrhage  arises  from  them,  the  bleeding  vessels  must  be 
secured  with  ligatures  in  the  ordinary  manner. 

All  authorities  are  agreed  as  to  the  non-advisability  of 
removing  the  fragments  of  a  broken  upper  jaw,  since,  owing 
to  the  vascularity  of  the  part,  they  almost  invariably  unite 
readily.  Malgaigne  says,  "  In  common  fractures  of  the 
upper  jaw  there  is  one  principle  which  surgeons  cannot  too 
carefully  bear  in  mind — that  is,  that  all  spunters,  however 
slightly  adherent,  should  be  scrupulously  preserved,  as  they 
become  reunited  with  wonderful  facility.  This  remark  was 
made  by  Saviard ;  Larrey  has  strongly  insisted  on  it,  and  we 
have  seen  that  M.  Eaudens,  who  so  much  urges  the  extrac- 
tion of  splinters,  has  likewise  made  a  special  exception  of 
these  cases."  (Packard's  translation,  p.  304.)  Hamilton 
remarks  that  the  experience  of  American  surgeons  during  the 
war  confirms  these  observations.  "  Owing  to  the  extreme 
vascularity  of  the  bones  composing  the  upper  jaw,  the  frag- 
ments have  been  found  to  unite  after  the  most  severe  a-un- 
shot  injuries  with  surprising  rapidity,  the  amount  of  necrosis 
and  caries  being  usually  inconsiderable  compared  with  the 
amount  of  comminution"  (p.  106). 

ISTotwithstanding  this,  however,  Hamilton  gives  a  lengthy 
account  of  a  case  of  fracture  of  the  upper  jaw,  in  which  he, 
in  conjunction  with  Dr.  Potter,  thought  it  necessary  to 
remove  a  fragment  which  included  the  floor  of  the  antrum 
and  had  been  drawn  down  and  displaced  in  an  attempt  to 
extract  a  loose  tootli.     "  The  time  occupied  in  this  operation 


04  FRACTURE  OF   THE  UPPER  JAW. 

was  at  least  one  hour,  during  which  we  were  every  moment 
in  the  most  painful  apprehension  lest  we  should  reach  and 
wound  the  internal  carotid  artery,  which  lay  in  such  close 
juxtaposition  to  the  knife  that  we  could  distinctly  feel  its 
pulsation.  After  its  removal  the  haemorrhage  was  for  an 
hour  or  more  quite  profuse,  and  could  only  be  restrained  by 
sj)onge  compresses  pressed  firmly  back  into  the  mouth  and 
antrum"  (p.  103).  Such  dangerous  operations  are  much  to 
be  deprecated,  and  cases  already  quoted  prove  that  even  after 
greater  separation  the  bone  will  thoroughly  reunite. 

Mention  has  been  made  of  the  difficulty  Wiseman  ex- 
perienced in  reducing  the  fragments  to  their  proper  position 
in  his  case,  and  the  means  he  adopted  to  overcome  it.  In 
the  majority  of  cases  the  finger  introduced  into  the  mouth 
and  passed  around  the  alveoli  will  readily  restore  any  irre- 
gularity, being  aided,  if  necessary,  by  the  introduction  of  a 
strong  elevator  or  pair  of  dressing  forceps  into  the  nostril. 
The  teeth  in  adjacent  fragments  may  be  advantageously 
wired  together  to  keep  them  in  position,  or,  where  there  is 
great  comminution  and  irregularity  of  the  alveoli,  a  piece  of 
soft  gutta-percha  may  be  adapted  to  them  so  as  to  hold  and 
support  the  fragments.  The  lower  teeth  should  not  be 
allowed  to  come  in  contact  with  this  until  it  is  thoroughly 
hardened,  or  they  would  become  imbedded  and  thus  cause 
its  displacement.  In  very  complicated  cases,  as  in  examples 
of  fractures  of  both  jaws,  the  vulcanite  interdental  splints 
of  Mr.  Gunning  (described  under  Fractures  of  the  Lower 
Jaw)  might  be  employed,  these  having  an  aperture  for  the 
introduction  of  food. 

Graefe  employed  an  apparatus,  of  which  the  following 
description  is  given  by  Malgaigne  (Packard's  translation, 
p.  301).  "  A  curved  steel  spring,  properly  padded,  is  applied 
over  the  forehead,  and  kept  in  place  by  a  strap  buckled 
around  the  occiput.  This  steel  has  at  each  side  a  hole  with 
a  screw  for  making  pressure  ;  and  a  steel  brace  to  which  it 
affords  a  x'oint  (Vcq^j^ici,  for  acting  steadily  on  the  dental 
arch.  Now  these  braces,  descending  to  the  level  of  the  free 
edge  of  the  upper  lip,  curve  backward  so  as  to  go  around 


graefe's  apparatus.  G5 

tlie  lip  without  wounding  it ;  getting  thus  at  the  dental 
arch,  they  again  curve  so  as  to  apply  themselves  to  it.  But 
as  the  pressure  of  the  braces  should  have  the  effect  of  keep- 
ing the  detached  teeth  in  proper  relation  with  the  rest,  a 
silver  trough  duly  padded  is  made  to  fit  over  both  to  a  suffi- 
cient length ;  and  upon  this  trough  the  braces  exert  their 
pressure.  It  is  easy  to  see  how,  by  altering  their  height  as 
regards  the  spring  over  the  forehead,  the  pressure  may  be 
regulated  to  the  right  degree." 

A  somewhat  similar  apparatus,  but  with  the  addition  of 
a  pad  which  can  be  applied  externally  so  as  to  support  the 
cheek,  was  brought  before  the  Surgical  Society  of  Paris,  in 
September,  1862,  by  M.  G  off  res. 

In  the  rare  cases  of  separation  of  the  maxillae,  a  spring 
passing  behind  the  head  and  making  pressure  upon  the 
maxillse  after  the  manner  of  Hainsby's  hare-lip  apparatus, 
might  be  advantageously  employed. 


66 


CHAPTER  V. 

GUNSHOT  INJURIES  OF  THE  JAWS. 

Gunshot  injuries  of  the  jaws  have  necessarily  been  inci- 
dentally referred  to  in  considering  fractures  of  those  bones 
separately,  but  it  will  be  convenient  to  class  the  injuries  of 
the  two  maxillae  by  fire-arms  together,  since  these  accidents 
affect  both  bones  in  the  majority  of  cases.  Laceration  of 
the  soft  tissues  and  consequent  haemorrhage  are  almost  con- 
stant accompaniments  of  wounds  of  the  face, and  tlie  mortality 
attending  them  is  high,  both  from  the  immediate  effects  of 
the  injury,  and  from  the  frequent  occurrence  of  secondary 
haemorrhage.  The  effects  of  the  modern  arms  of  precision 
contrast  unfavourably  in  this  respect  with  those  of  the 
round  bullet  of  the  old  fire-lock,  for  though  the  latter  fre- 
quently lodged  in  one  of  the  cavities  of  the  face  for  an  in- 
definite time,  the  irregular  mass  of  metal  driven  with  tre- 
mendous velocity  by  the  modern  rifle  comnn'ts  greater  havoc, 
splintering  the  bones  and  lacerating  the  soft  tissues  most 
extensively. 

The  Surgeon-General  of  the  American  army  reported  in 
November,  1865  (Circular  No.  6,  Washington),  that  from 
the  commencement  of  the  war  to  October,  1864,  of  4167 
wounds  of  tlie  face  reported  to  him,  there  were  1579  frac- 
tures of  the  facial  bones  ;  and  of  these  891  recovered  and 
171  died — the  terminations  being  still  to  be  ascertained  in 
517  cases.  Secondary  haemorrhage  was  the  principal  cause 
of  mortality  in  these  cases,  and  the  carotid  had  frequently 
been  tied  with  the  result  of  postponing  for  a  time  the 
fatal  result. 

The  Crimean  returns  from  the  1st  of  Ajjril,  1855,  to  the 


CRIMEAN    EXPERIENCE   OF    CUNSHOT   WOUNDS.       (37 

end  of  the  war,  show  533  wounds  of  the  face,  of  which  the 
hones  were  injured  in  107  instances.  445  patients  returned 
to  duty,  74  were  invalided,  and  14  died. 

Of  21  cases  of  wounds  of  the  face  with  injury  to  the 
bones  from  the  Indian  Mutiny  reported  by  Dr.  Williamson, 
six  were  examples  of  fracture  of  tlie  lower  jaw,  and  of  these 
three  remained  ununited. 

The  following  extract  is  from  the  official  "  Medical  and 
Surgical  History  of  the  British  Arnij'  in  tlie  Crimea,"  vol. 
ii.  p.  305,  and  illustrates  the  experience  of  that  war,  which 
has  been  largely  confirmed  by  that  of  the  later  American 
war : — "  Wounds  of  the  face,  though  presenting  often  a 
frightful  amount  of  deformity,  are  not  generally  of  so 
serious  a  nature  as  their  first  appearance  might  lead  the 
uninitiated  to  expect.  The  reason  of  this,  apart  from  the 
fact  that  the  face  contains  no  vital  organ,  seems  obviously 
to  be  the  very  free  supply  of  blood  which  this  part  receives. 
From  this  cause  the  fleshy  structures  readily  heal,  and  even 
the  bones  are  so  supplied  that  extensive  necrosis  rarely 
happens,  Tlie  bone  tissues,  also,  are  softer  than  tlie  long 
bones  of  the  extremities,  and  we  therefore  but  seldom  here 
meet  Math  long  fissures  and  extensive  necrosis  as  a  result 
of  concussion  of  bone,  so  often  seen  in  them.  This  leads  us 
to  the  very  important  practical  inference,  not  in  this  situa- 
tion, as  a  rule,  to  remove  bony  fragments,  unless  the  com- 
minution be  great,  or  the  fragment  completely  detached 
from  the  soft  parts.  Even  partially  detached  teeth  will  often 
be  found  not  to  have  lost  their  Aitality,  and,  if  carefully  re- 
adjusted, will  become  useful.  There  is  indeed  no  great 
object  beyond,  perhaps,  the  present  comfort  of  the  patient 
to  be  attained  in  removing  eitlier  fragments  of  bone  or 
loosened  teeth  in  the  great  majority  of  instances.  If  tliey 
die,  the)^  become  loose,  and  are  readily  lifted  aw^ay  without 
trouble  to  the  surgeon,  and  but  little  pain  to  the  patient. 
This  observation  is  especially  applicable  to  fractures  of  the 
lower  jaw.  Surgeons  in  this  war  have  seen  so  many  cases 
of  badly-fractured  instances  of  this  kind  unite,  and  that 
with  a  very  small  amount  of  deformity,  that  men  of  cx- 

F   2 


(38  GUNSHOT  INJURIES   OF   THE   JAWS, 

perience  are  now  excessively  chary  of  removing  any  portion 
of  this  bone,  unless  it  has  become  dead,  or  the  fragment  is 
so  situated  as  to  interfere  considerably  Avith  the  adjustment 
of  the  remainder,  or  the  bone  so  much  comminuted  as  to 
give  no  probable  hope  of  its  becoming  consolidated,  or  so 
sharply  angular  as  to  threaten  further  injury  to  the  soft 
parts,  or  to  interfere  materially  with  their  adjustment  and 
retention  in  situ.  In  these  fractures  of  the  lower  jaw, 
much  less  support  and  adjustment  than  we  are  in  the  habit 
of  thinking  advantageous  in  ordinary  cases  of  fracture  of  it, 
will  frequently  be  found  necessary,  or  even  admissible.  A 
complicated  apparatus  cannot  be  borne  at  first,  on  account 
of  the  condition  of  the  soft  parts,  and  the  application  of 
slight  support  by  a  gutta-perclia  or  Startin's  wire  splint,  and 
a  split  bandage,  is  all  that  can  be  done.  Any  attempt  at 
ligaturing  the  teeth  is  very  generally  not  only  useless,  but 
injurious,  and  it  is  surprising  how  the  parts  often  as  it  were 
adjust  themselves,  with  but  little  aid  from  the  surgeon. 
One  interesting  case  may  be  mentioned  where  the  whole 
of  the  bone,  from  anf:;le  to  anole,  was  so  comminuted 
by  guns]  lot  that  no  choice  was  left  but  to  remove  the 
fragments.  Tlie  injury  to  the  soft  parts  was  very  con- 
siderable, and  one  difllculty,  occasioned  by  the  loss  of  all 
support  in  front — viz.,  the  tendency  of  the  tongue  to  fall 
backwards  and  close  the  opening  of  the  glottis,  well  illus- 
trated. The  man,  however^  generally  remedied  this  himself 
with  his  fingers,  and  nothing  was  done,  or  required  to  be 
done,  on  this  account  beyond  carefully  watching  him.  He 
naturally,  as  it  were,  adopted  a  position  on  liis  side,  resting 
maiidy  on  his  forehead,  so  as  to  have  the  face  as  much  in 
the  prone  posture  as  possible,  and  tlius  tlie  weight  of  tlie 
organ  assisted  in  keeping  it  in  position." 

Gunshot  wounds  of  tlie  upper  jaw  through  the  mouth 
are  usually  of  suicidal  origin,  and  of  this  a  specimen,  pre- 
sented by  myself,  is  now  in  the  Museum  of  the  College 
of  Surgeons  (832),  being  the  skull  of  a  man  who  fired  a 
pistol  into  his  mouth.  The  red  lines  on  the  preparation 
mark  the  outline  of  the  fracture,  and  it  will  be  seen  that  a 


FRACTURE   OF    THE   LOWER   JAW.  69 

great  part  of  the  hard  palate  was  driven  in,  and  that  the 
bullet,  after  fracturing  extensively  the  base  of  the  skull, 
carried  away  a  considerable  portion  of  the  vault  of  the  cra- 
nium. The  malar  bone,  with  the  outer  wall  of  the  antrum, 
is  broken  off  on  the  rioht  side,  and  the  malar  bone  on  the 
left  is  separated  from  the  maxilla  at  the  articulation.  In  a 
second  case  of  the  kind,  which  I  also  had  the  opportunity  of 
examining  immediately  after  death,  the  injuries  were  similar 
in  extent. 

In  the  preparation  referred  to  there  is  an  oblique  fracture 
of  the  lower  jaw  on  the  left  side,  running  backwards  through 
the  socket  of  the  first  molar  tooth,  and  an  oblique  crack  has 
been  produced  on  the  inner  surface  of  the  right  side  of  the 
bone,  in  an  exactly  corresponding  position.  Fracture,  of  the 
jaw  had  occurred  also  in  the  second  case  alluded  to,  and  has 
been  frequently  noticed  under  similar  circumstances,  the 
fracture  depending  upon  the  concussion  of  the  explosion 
and  the  rapid  development  of  gas  within  the  mouth.  This 
is  not  without  exception,  however,  since,  in  the  University 
College  Museum,  there  is  the  skull  of  a  man  who  fired  a 
pistol  into  his  mouth,  in  which  the  palate  is  extensively 
damaged,  but  the  lower  jaw  perfect.  When  the  bullet 
actually  enters  the  mouth  the  injury  is  usually  immediately 
fatal,  but  Otto  Weber  has  recorded  {Handbucli  clcr  Allge- 
meinen  unci  Speciellen  Chirurgie,  Part  III.  1866)  a  case  of 
recovery : — "  The  patient,  through  despair  arising  from 
pecuniary  embarrassments,  determined  to  shoot  himself  in 
the  churchyard.  He  held  the  pistol  before  his  open  mouth, 
and,  after  firing,  fell  senseless  to  the  ground.  After  some 
time  he  came  to  himself,  looked  for  his  spectacles,  which  had 
fallen  off  his  face,  and  made  the  gravedigger  bring  him  to 
me.  The  palatal  vault  was  simply  perforated,  and  the  ball, 
completely  flattened,  was  sticking  in  the  body  of  the  sphenoid 
bone,  where  it  could  be  felt  by  the  index  finger  introduced 
into  the  hole  by  which  it  had  entered.  After  some  fruitless 
attempts  to  extract  it,  it  fell  into  the  patient's  throat  and  he 
spat  it  out.  Subsequently  the  hole  in  the  palate  completely 
closed  up  again,  and  the  patient  recovered  both  physically 


70  GUNSHOT  INJURIES   OF   THE  JAWS. 

and  morally."  In  this  case  tlic  lower  jaw  does  not  appear 
to  have  suffered,  but  Mr.  Barrett  has  shown  nie  the  model 
of  a  case  in  which  a  pistol  bullet,  fired  at  the  open  mouth, 
glanced  off  an  incisor  tooth,  and  ran  up  the  side  of  the  face, 
emerging  near  the  malar  bone,  and  where  nevertheless  the 
lower  jaw  was  broken  by  the  explosion. 

I  was  once  called  in  by  Dr.  AVhitmarsh,  of  Hounslow, 
to  see  a  patient  wlio  Imd  fired  a  pistol,  loaded  with  small 
shot,  into  his  mouth,  smashing  the  palate  and  fracturing 
the  lower  jaw  in  two  places  by  the  explosion,  but  who 
eventually  made  a  good  recovery ;  and  in  tlie  Lancet,  Nov.  7, 
1868,  will  be  found  a  remarkable  case  under  the  care  of 
Mr.  Sydney  Jones,  of  recovery,  after  a  similar  injury,  com- 
plicated by  division  of  one  optic  nerve  a-nd  injury  to  the 
l:)rain. 

Because  a  bullet  has  entered  the  mouth,  and  inflicted 
injury  upon  the  bones  of  the  palate,  &c.,  it  does  not  neces- 
sarily lodge  there  ;  thus,  in  the  "  Medical  and  Surgical 
History  of  the  Crimea,"  is  the  case  of  John  Collins,  97th 
Regiment,  who  was  wounded  on  the  8th  September  and  sent 
to  hospital  on  the  14th,  having  been  struck  by  a  musket-ball, 
which  had  entered  the  mouth  slightly  cutting  the  upper  lip, 
and  had  comminuted  the  palate  i:)late  of  the  superior  maxilla, 
and  appeared  to  be  lodged  somewhere  among  the  ethmoid 
cells.  There  was  but  little  constitutional  disturbance.  All 
the  incisor  teeth  of  the  upper  jaw  became  dead  and  liad  to 
be  removed,  as  well  as  some  fragments  of  the  palate  plate, 
but  tlie  wound  slowly  healed  and  finally  filled  uji,  leaving 
the  man  Ijut  little  tlie  worse,  except  for  the  loss  of  his  teeth. 
Various  careful  examinations,  made  at  different  times,  failed 
to  detect  the  presence  of  any  foreign  body,  and  the  man  him- 
self afterwards  stated  that  he  had  alwa}-s  fancied  the  bullet 
fell  out  during  his  progress  from  the  trenches  to  the  regi- 
mental hospital. 

Injuries  of  the  palate  ma}'  also  be  produced  by  wounds  of 
the  face  ;  thus,  Mr.  Cox  Smith,  of  Chatham,  records  the  case 
of  a  soldier  who  came  undcjr  his  care,  in  whom  the  jaw  and 
palate  had  been  extensively  fractured,  and  the  incisor  teeth 


LODGMENT   OF   MISSILES. 


71 


driven  in,  as  seen  in  fig.  31a,  so  that  the  patient  was  unable 
to  masticate  or  speak.  By  extracting  these  teeth  (fig.  3lh), 
Mr.  Smith  was  able  to  adapt  a  set  of  artificial  teeth,  so  as 
to  restore  to  the  patient  the  use  of  his  mouth  for  all  pur- 
poses. 

Missiles,  striking  from  without,  occasionally  lodge  for  a 
considerable  time  in  the  antrum  or  nose,  and,  sometimes, 
without  their  presence  being  suspected.  In  the  "  Medical 
and  Surgical  History  of  the  Crimean  War,"  will  be  found 
the  case  of  a  soldier  who  received  a  severe  wound  of  the 
face.  A  grapeshot,  weighing  seventeen  ounces,  lodged  in 
the  jaw,  having  displaced  the  palate,  with  a  portion  of  the 
maxilla,  and  all  the  molar  teeth  of  the  right  side,  into  the 


Fig.  31«. 


Fig.  31&. 


mouth.  Here  it  was  found  necessary  to  enlarge  the  wound 
and  remove  the  fragments  (contrary  to  the  general  rule  of 
practice)  before  the  ball  could  be  extracted,  but  the  patient 
made  a  good  recovery,  notwithstanding  severe  secondary 
Koemorrhage.  Still  more  remarkable,  however,  are  cases 
which  have  occurred  in  civil  practice,  where  the  breech  of  a 
burst  fowling-piece  has  lodged  for  years  in  the  antrum.  A 
remarkable  case  of  this  kind  was  reported  in  the  Ediiiburgh 
Medical  Journcd,  of  September,  1856,  by  Dr.  Fraser,  of  New- 
foundland, who  removed  a  piece  of  metal,  weighing  more 


72  GUNSHOT   INJUEIES   OF   THE   JAWS. 

than  four  ounces,  and  measuring  nearly  three  Indies  in 
length,  from  the  jaw  of  a  man  who  had  sustained  an  accident 
seven  years  before.  A  still  more  extraordinary  case  is  re- 
corded in  the  Museum  of  Guy's  Hospital,  which  possesses  a 
model  of  the  breech  of  a  gun  which  had  been  lodged  in  the 
face  of  a  man  for  twenty-one  years  !  "  The  patient  was 
shooting  birds  when  the  gun  burst,  the  right  eye  was  knocked 
out,  and  the  roof  of  the  orbit  destroyed,  and  through  it  the 
brain  protruded  ;  the  latter  sloughed,  and,  after  a  long  ill- 
ness, the  man  recovered.  At  the  latter  end  of  1856  he  was' 
suddenly  seized  with  symptoms  of  choking,  as  from  a  foreign 
body  in  the  throat,  and,  on  putting  his  finger  in  his  mouth 
to  remove  it,  he  drew  forth  the  breech  of  a  gun,  much  oxi- 
dized and  covered  with  purulent  matter.  It  is  supposed  that 
the  piece  of  iron  broke  through  the  floor- of  the  orbit,  and 
had  been  lodging  in  the  antrum  ever  since." 

In  connection  with  this  subject  may  be  mentioned  the  case 
of  a  knife-blade  lodged  in  the  antrum  for  forty-two  years, 
and  finally  coming  out  of  the  nostril,  reported  in  the  Bulletino 
di  Bologna,  May,  1864. 

Cannon  shot,  striking  the  face,  inflict  the  most  frightful 
injuries  upon  the  jaws,  which  are  usually  fatal ;  thus  Pro- 
fessor Longmore  mentions  ("  System  of  Surgery,"  vol.  i.)  the 
case  of  an  officer  of  Zouaves  in  the  Crimea,  who  had  the 
whole  face  and  jaw  carried  away  by  a  cannon-ball,  the  eyes 
and  tongue  being  included,  so  that  there  remained  only  the 
cranium.  The  patient  survived  for  twenty  hours.  Guthrie 
also  relates  a  very  similar  case,  as  having  occurred  at  the 
siege  of  Badajos.  The  wars  of  the  first  Napoleon  afibrded 
some  frightful  examples  of  injury  to  the  jaws,  which  the 
unfortunate  patients  survived  for  years  in  one  of  the 
military  asylums  of  Paris.  The  accompanying  drawing 
(fig.  32),  taken  from  an  able  paper  by  M.  Emile  Debout, 
"  On  the  Mechanical  Picstoration  of  the  Maxillae"  {British 
Journal  of  Dental  Science,  April,  1864),  shows  the  condition 
of  a  corporal  "udio  was  struck  by  a  cannon-ball  at  the  siege 
of  Alexandria,  in  1800.  The  shot  carried  away  the  greater 
part  of  the  face,  including  three-fourths  of  the  lower  jaw, 


INJURY   FROM   CANNON-BALL. 


73 


and  part  of  the  tongue,  and  the  man  was  thought  to  be 
dead.  Under  the  solicitous  care  of  Baron  Larrey  lie  re- 
covered, however,  and  lived  for  more  than  tAventy  years. 
"  It  can  be  seen  at  a  glance  that  speech  and  mastication  were 
impossible.  Poor  Vaute  concealed  the  deformity  by  wearing 
a  mask,  gilt  inside,  and  imitating  the  colour   of  the   skin 

Fig.  32. 


outside.  He  could  even  by  means  of  this  cover  make  himself 
a  little  understood,  but  his  greatest  distress  arose  from  the 
incessant  escape  of  the  saliva,  which  was  so  great  as  to  satu- 
rate in  succession  a  number  of  linen  compresses  in  the  course 
of  the  day.  After  supporting  his  misfortune  heroically  for 
so  many  years,  he  put  an  end  to  his  misery  in  1821.  In 
order  to  complete  the  history  of  a  case  in  which  he  had  felt 
so  deep  an  interest,  Larrey,  on  learning  the  death  of  Vaute, 
procured  his  head,  the  state  of  which  he  described. 

The  loss  of  substance  occasioned  by  the  ball  was  limited' 
to  the  elliptic  segment  seen  in  the  portrait.     The  left  malar 


74  GUNSHOT   INJURIES   OF   THE   JAWS. 

bone  had  been  carried  away.  The  arch  of  the  palate  and 
the  nasal  fossae  down  to  the  ethmoid  had  been  destroyed. 
The  inferior  and  internal  orbital  walls,  down  to  the  base  of 
the  skull,  had  been  also  destroyed.  Two-thirds  of  the  lower 
jaw  were  wanting.  The  right  half  of  the  middle  portion  of 
this  bone,  with  three  of  the  teeth,  was  found  adherent  to  a 
part  of  the  surface  of  the  right  ramus,  which  had  been 
fractured.  The  portion  supporting  the  coronoid  process  and 
the  condyle  was  considerably  depressed  backwards  to  meet 
the  other  fragments  of  this  bone ;  but,  as  they  were  not  in 
sufficiently  close  contact,  they  had  not  grown  to  each  other. 
All  the  edges  of  the  bones  broken  away  by  the  ball  had  become 
thinned  and  rounded,  forming,  with  the  corresponding  soft 
parts,  a  puckered,  irregular  border  surrounding  the  gulf  in 
the  middle  of  the  face.  To  j)erpetuate  the  history  of  the 
case,  Baron  H.  Larrey  has  had  the  prej^aration  of  the  head 
placed  in  the  museum  of  the  Hospital  of  Val  de  Grace." 

Fragments  of  shell  produce  as  frightful  injuries  as  round 
shot,  though  the  results  are  not  so  immediately  fatal.  Pro- 
fessor Longmore  recorded  {Lancet,  1855)  a  case  of  injury  of 
the  kind  occurring  under  his  notice  in  the  Crimea,  in  which 
the  right  half  of  the  palate  was  jammed  in,  and  fixed  at  right 
angles  to  the  other  half,  and  the  whole  superior  maxilla  was 
much  comminuted.  The  lower  jaw  was  broken  in  three 
places,  and  there  was  extensive  laceration  of  the  soft  parts. 
Great  difficulty  was  met  with  at  first  in  unlocking  the  parts 
of  the  palate  which  had  been  driven  into  each  other,  and 
when  they  were  separated  the  right  half  hung  down  loosely 
in  the  mouth.  The  j)arts  were  carefully  restored  to  position, 
and  tlie  patient  made  a  good  recovery  without  deformity. 

In  the  Appendix  will  be  found  the  report  of  a  case 
(Case  V.)  of  extensive  injury  to  the  jaws  by  a  piece  of  shell, 
in  which  Dr.  D.  Lloyd  Morgan,  E.N.  (to  whom  I  am  in- 
debted for  the  report),  was  obliged  to  tie  the  common 
carotid  artery  for  secondary  hasmorrhage,  with  success,  so  far 
as  the  operation  was  concerned,  though  the  patient  died  of 
cholera  some  time  after. 

A  charge  of  small  shot,  if  fired  near  enough  to  the  face 


BULLET   WOUNDS.  75 

to  do  more  than  lodge  iu  the  skin  or  jaw-ljouu  (of  which 
there  is  a  good  example  in  the  Middlesex  Hospital  Museum), 
will  produce  as  serious  injuries  to  the  jaws  as  a  bullet.  In 
the  Lancet  of  10th  November,  1860,  is  the  report  by  ]\Ir. 
Swete,  of  Wrington,  of  a  case  of  very  severe  injury  to  the 
jaws  from  a  charge  of  "  dust  shot,"  fired  at  a  distance  of 
four  feet  from  the  patient,  a  boy  aged  nine  years.  The 
charge  entered  the  left  side  of  the  face,  and  passed  out  in 
front  of  the  right  ear,  carrying  away  with  it  the  greater  part 
of  the  lower  lip  and  jaw,  and  the  whole  of  the  chin.  Several 
pieces  of  bone  and  teeth  were  picked  up  in  an  adjoining  field, 
at  a  distance  of  ten  yards.  There  was  an  extensive  ragged 
wound  of  the  face,  extending  nearly  to  the  ear,  the  right  half 
of  the  upper  lip  being  destroyed,  and  the  teeth  and  alveolus 
of  the  same  side  carried  away.  The  lower  jaw  was  shot 
away  at  the  angle  on  the  right  side,  and  on  the  left  about  an 
inch  of  the  body  of  the  jaw  and  one  molar  tooth  remained. 
Mr.  Swete  trimmed  the  ragged  edges  of  the  jaw  and  brought 
the  lacerated  parts  together,  and,  contrary  to  expectation, 
the  patient  recovered  and,  by  means  of  a  plastic  operation, 
was  restored  to  a  condition  of  considerable  comfort. 

Fracture  of  the  lower  jaw  alone  may  be  produced  by 
bullets,  and  in  this  case  the  haemorrhage  is  often  se^■ere 
from  the  divided  facial  artery,  wliicli  vessel  is  generally  in- 
volved. In  the  Edinhurgh  Medical  Journal,  Sept.  1860, 
Dr.  John  Brown,  of  the  Bengal  JMedical  Service,  records  four 
cases  of  the  kind  which  are  good  examples  of  the  variety  of 
injury  iniiicted  by  a  bullet : — 

1.  Was  a  gunshot  injury  of  the  jaw,  attended  by  profuse 
haemorrhage.  The  facial  artery  was  secured,  and  a  large  por- 
tion of  the  comminuted  bone  removed.  The  patient  did  well. 

2.  Was  a  gunshot  wound  at  the  symphysis.  There  was 
a  depression  in  the  bone  at  the  spot,  but  the  ball  had  not 
perforated  it.     Did  well. 

3.  Occurred  in  Lucknow.  A  Sikh  was  sliot  in  the  right 
side  of  the  lower  jaw ;  there  was  great  arterial  haemorrhage 
from  the  facial  artery,  with  a  small  wound  over  the  angle 
and  a  larger  one  over  the  symphysis.      Both  were  laid  into 


76  GUNSHOT    INJURIES    OF   THE   JAWS. 

one,  fragments  were  removed,  and  the  facial  artery  tied. 
Died  twelfth  day. 

4.  Ball  traversed  the  mouth  and  fractured  both  sides  of 
the  lower  jaw  near  the  angles.  Died  from  pyaemia  on  twenty- 
first  day. 

Tlie  Catalogue  of  the  Surgical  Section  of  the  United 
States  Army  Medical  IMuseum  (1866)  contains  numerous 
records  of  injuries  of  this  kind,  from  which  the  following 
may  be  quoted  as  most  remarkable : — 

"  3350.  The  riglit  half  of  the  inferior  maxilla  fractured 
l)y  a  musket-ball,  a  small  portion  of  which  is  attached. 
The  missile  entered  the  mouth,  struck  the  alveolar  ridge 
at  the  molar  teeth,  comminuting  it,  and  causing  oblique 
fracture  of  the  body  of  the  bone.  The.  patient  died  the 
same  day  from  haemorrhage,  from  rupture  of  the  internal 
maxillary  artery. 

"  1451.  Wet  preparation  of  the  right  side  of  the  body  of 
the  inferior  maxilla,  fractured  and  comminuted  by  a  musket- 
ball  at  the  angle.  A  fragment  containing  the  molar  teeth 
is  driven  inward,  and  other  fragments  remain  in  situ,  the 
total  amount  of  bone  shattered  being  two  inches.  The  ball 
lodged  in  the  thyroid  cartilage,  causing  death  by  suffocation 
on  the  nineteenth  day. 

"  3542.  The  inferior  maxilla  fractured  and  comminuted 
by  a  musket-ball.  The  alveolar  ridge  and  the  teeth  are 
entirely  removed  ;  there  is  a  horizontal  fracture  of  the  left 
ramus  passing  through  the  inferior  dental  foramen ;  on  the 
right  side  there  is  a  transverse  fracture  of  the  body  of  the 
bone  at  the  last  molar,  and  an  obli(|ue  vertical  fracture  at 
the  symphysis.  Tlie  i)atient  died  from  the  effect  of  the 
wound  of  the  tongue,  causing  lui'morrliago,  for  whicli  the 
left  common  carotid  was  ligated." 

The  experience  of  English  surgeons  in  the  Crimea,  already 
referred  to,  has  so  completely  settled  the  question  of  opera- 
tive interference  in  cases  of  gunshot  wounds  of  tlie  lower 
jaw,  that  few  military  surgeons  would  be  inclined  to  follow 
the  example  of  M.  liaudens  (see  Guthrie's  "  Commentaries," 
p.  501)   in  laying  open  the  cheek  and  removing  or  rounding 


FALSE   JOINT   IX   THE   LOWER   JAW.  11 

off  all  fragments.  Where  spicula  are  much  displaced,  or 
where  a  bleeding  vessel  is  to  be  reached,  it  may  be  occa- 
sionally necessary  to  enlarge  the  wound,  as  in  one  of  the 
cases  already  quoted,  but  this  must  be  considered  the  excep- 
tion rather  than  the  rule. 

A  fracture  inay  possibly  be  produced  indirectly  without 
the  bullet  actually  striking  the  jaw  ;  of  this  the  following 
extraordinary  instance  occurred  at  the  battle  of  Balaclava. 
A  man  of  the  4th  Light  Dragoons  received  a  compound 
fracture  of  the  lower  jaw  by  a  grape-shot  striking  the  flat 
of  his  sabre,  while  at  the  slope,  and  driving  it  against  the 
side  of  his  face  and  head.  The  blade  was  bent,  but  not 
broken,  and  the  missile  did  not  touch  the  man. 

Fragments  of  the  jaw  have  been  driven  into  other  parts 
of  the  body,  and  even  into  that  of  a  neighbour.  In  the 
"  Medical  and  Surgical  History  of  the  Crimean  War"  is  re- 
ported the  case  of  a  soldier  who  was  shot  in  the  right  cheek, 
the  ball  glancing  downwards  and.  lodging  in  the  neck,  from 
which  it  was  extracted.  Subsequently  a  foreign  body  was 
detected  behind  the  right  clavicle,  which  was  cut  down  upon 
and  proved  to  be  a  portion  of  the  lower  jaw.  Hamilton, 
also,  in  his  "  ]\Iilitary  Surgery"  (p.  255),  mentions  the  case 
of  a  Confederate  soldier,  who  was  kneeling  and  bending  for- 
ward when  he  received  a  rifle  ball  upon  his  four  lower  in- 
cisor teeth.  The  ball  and  teeth  disappeared,  but  were  sub- 
sequently removed  from  beneath  the  skin  at  the  top  of  the 
sternum. 

The  frequent  occurrence  of  a  false  joint  after  gunshot 
injuries  of  the  lower  jaw  has  been  already  adverted  to  in  the 
section  upon  False  Joint.  Since  in  gunshot  cases  a  loss 
of  substance  has  usually  taken  place  which  reiiders  the  union 
of  the  remaining  portions  an  impossibility,  some  mechanical 
contrivance  should  be  adapted  by  the  dentist  to  hold  the 
parts  in  their  proper  position  and  enable  the  patient  to  mas- 
ticate. A  case  of  false  joint  near  the  symphysis,  treated  in 
this  manner  most  successfully  by  Mr,  Cox  Smith,  has  been 
already  referred  to,  and  will  be  found  at  page  31.  Figs. 
33  and  34  show  the  effects  of  mechanical  treatment  in  sepa- 


78 


GUNSHOT  INJURIES   OF   THE   JAWS. 


rating  the  fragments  and  the  filling  of  the  gap  by  artificial 
teeth,  and  should  be  contrasted  with  figs.  9  and  10.  The 
sooner  such  apparatus  is  adapted  after  the  receipt  of  the  in- 


FiG.  3.3. 


Fig.  34. 


jury  the  better,  since,  as  will  be  presently  shown,  the  muscles 
liave  a  constant  tendency  ^to  draw  the  two  sides  of  the  jaw 
together.  Not  only  is  this  effect  produced  upon  the  lower  jaw, 
but  there  appears  to  be  a  secondary  effect  produced  in  these 
cases  upon  the  upper  jaw,  the  alveolar  arch  of  which  be- 
comes gradually  contracted  from  v/ant  of  proper  antagonism. 
M.  Debout,  in  the  paper  already  referred  to,  gives  the  case 
of  a  French  corporal,  who,  during  the  Italian  campaign,  was 
wounded  by  a  fragment  of  shell,  whicli  fractured  the  lower 
jaw  and  severely  lacerated  the  integuments.  The  connni- 
nuted  fragments  w^ere  removed,  and  the  soft  parts  brought 
together  with  sutures,  so  as  to  restore  as  far  as  possible  the 
floor  of  the  mouth.  All  that  could  be  obtained,  however, 
was  to  form  a  sort  of  channel  concealed  by  the  beard,  as 
shown  in  fig.  35,  by  which  tlie  saliva  flowed  in  great  abun- 
dance. When  the  patient  arrived  at  the  Yal  de  Grace  lie 
was  placed  under  the  care  of  Professor  Legouest,  at  whose 
request  M.  Preterre,  the  dentist,  was  called  in.  The  latter 
gentleman,  before  maldng  any  attempt  to  remedy  the  muti- 
laiion  by  restoring  the  lower  jaw,  thought  it  necessary  first 
of  all  to  have  an  apparatus  made  for  the  purpose  of  pre- 
venting the  contraction  of  the  dental  arch.     Fig.  36  shows 


CONTRACTION   OF   UPPER   JAW. 


79 


the  apparatus    in  its  place,  A,  c  pointing  to    the   position 
in  which  the  alveolar  border  was  wlien  the  case   was  first 


Fig    35. 


seen.     The  completion  of  the  case  was  prevented  by  the 
patient  quitting  the  hospital. 


Fig.  36. 


80 


GUNSHOT   INJURIES    OF   THE   JAWS. 


Complete  or  nearly  comjDlete  destruction  of  the  lower  jaw 
by  a  cannon-ball  has  more  than  once  occurred^  the  patients 
surviving  for  many  years,  and  the  deformity  being  palliated 
by  the   use    of  a  silver   chin  (fig.  37).     The    accompanying 

Fig.  37. 


illustration  (fig.  38)  from  M.  Debout's  paper,  shows  the  dis- 
section of  a  case  of  the  kind  more  than  thirty  years  after 


Fig.  38. 


DESTRUCTION   OF   LOWER   JAW.  81 

tlie  receipt  of  the  injury,  the  history  being  as  follows  : — At 
the  battle  of  Jena,  Vernet  had  the  body  and  left  ramus  of 
the  lower  jaw  carried  away  by  a  cannon-ball.  The  soft 
parts,  bruised  and  torn,  hung  down  in  front  of  the  neck, 
and  the  tongue  was  much  injured  from  the  tip  along  the 
left  side.  At  the  ambulance  the  parts  were  adjusted  as  well 
as  possible,  and  the  dressing  completed.  An  abundant  sup- 
puration ensued ;  splinters  were  detached  from  the  ex- 
tremities of  the  bones,  and  the  whole  was  healed  in  three 
months. 

Piibes,  in  1818,  describes  thus  the  condition  of  the  parts 
when  Vernet  had  attained  the  age  of  forty-four  : — "  The  soft 
parts  and  loose  flaps  of  the  lips,  chin,  and  cheeks  have  be- 
.  come  agglutinated  at  the  upper  part  of  the  neck,  above  and 
to  the  side  of  the  larynx  at  the  root  of  the  tongue,  where 
they  form  by  their  adhesion  divers  folds  and  cicatrices. 
The  opening — the  mouth — is  situated  beneath  the  arch  of 
the  palate ;  the  tongue  lies  concealed  in  the  soft  parts,  and 
retracted  towards  the  pharynx ;  the  lower  part  of  the  tongue 
is  closely  adherent,  and  in  a  manner  fixed  to  the  parts 
beneath  it,  so  that  the  tip  can  be  projected  only  to  the  left, 
and  not  forwards. 

"  The  patient  wears  a  silver  double  chin,  with  which  he 
can  speak  pretty  distinctly  ;  but  is  much  inconvenienced  by 
the  incessant  escape  of  the  saliva." — (Diet,  des  Sciences 
Medicales,  vol.  xxix.  p.  425.) 

Vernet  lived  twenty  years  longer  ;  and  some  years  before 
his  death  the  mouth-opening  became  so  narrow  that,  instead 
of  being  obliged  to  change  the  cloths  or  sponges,  into  which 
the  saliva  used  to  flow,  five  or  six  times  a  day,  he  scarcely 
wetted  one. 

In  this  case  the  steady  contraction  of  the  cicatricial  tissues 
of  the  mouth  had  a  beneficial  tendency.  The  effect  pro- 
duced upon  the  teeth  of  the  upper  jaw  is  well  seen  in  the 
illustration. 

In  the  United  States  Army  Museum  is  a  remarkable 
specimen  of  attempted  bony  repair  of  a  nearly  as  extensive 
injury,  which   is    thus    described  : — "  1162.      The   inferior 

G 


82  GUNSHOT  INJURIES   OF   THE   JAWS. 

maxilla,  probably  fractured  by  a  musket-ball.  The  body  of 
the  bone  has  been  removed  nearly  to  the  angle  on  each  side, 
and  an  irregular  plate  of  new  bone,  measuring  two  inches 
in  length,  three-fourths  of  an  inch  in  width,  and  one-half 
inch  in  thickness  has  formed  anteriorly,  and  is  connected  to 
the  rami  on  either  side  by  ligamentous  bands.  The  patient 
died  one  hundred  and  one  days  after  the  receipt  of  the 
injury." 


83 


CHAPTER  Vr. 


DISLOCATION    OF    THE    JAW. 


Dislocation  of  the  lower  jaw  may  be  unilateral  or  bilateral, 
the  latter  being  the  more  frequent  \^ariety,  since  of  28  cases 
of  dislocation  given  by  Giralcles,  15  were  of  both  condyles  ; 
and  of  76  cases  given  by  Malgaigne,  54  were  the  same,  31 
of  these  last  being  in  women.  Bilateral  dislocation  occurs 
most  frequently  in  middle  age,  though  it  is  not  unknown  in 
youth  and  old  age ;  thus  Sir  Astley  Cooper  gives  the  case  of 
a  child  who  experienced  the  accident  from  forcing  an  apple 
into  his  mouth,  and  both  K^laton  and  Malgaigne  have  met 
with  it  in  old  people  of  sixty-eight  and  seventy-two  years 
of  age.  The  possibility  of  dislocation  of  the  jaw  following 
traction  on  the  chin  with  the  finger  or  hook  in  delivery 
need  be  only  alluded  to,  since  the  occurrence  must  be 
unknown,  or  nearly  so,  in  the  case  of  living  children.  The 
less  frequent  occurrence  of  the  accident  in  the  extremes  of 
age  may  be  explained,  partly  by  the  smaller  liability  of 
children  and  old  people  to  external  violence,  and  also  by  the 
fact  that,  owing  to  the  obtuseness  of  the  angle  formed 
between  the  ramus  and  the  body  of  the  bone  at  those  ages, 
the  leverage  of  the  jaw  is  diminished,  and  the  muscles  do 
not  act  in  such  vertical  lines  as  in  middle  age.  The  expla- 
nation offered  by  M.  ISTelaton — viz.,  that  in  youth  the  coronoid 
processes  are  too  short,  and  in  old  age  directed  too  far  back, 
to  impinge  upon  the  malar  process  of  the  upper  jaw — 
appears  to  be  untenable,  and  will  be  referred  to  in  describing 
the  pathology  of  dislocation. 

The    causes    of    dislocation    are    yawning,    vomiting,   or 
shouting,  in  all  of    which  actions  the  patient's    mouth    is 

G  2 


84  DISLOCATION   OF  THE   JAW. 

opened  to  its  fullest  extent ;  or  it  may  result  from  blows 
or  the  kicks  of  animals,  and  tins  is  particularly  the  case 
with  the  unilateral  form  of  the  affection.  Causes  acting 
within  the  mouth  may  also  produce  dislocation — e.g.,  the 
introduction  of  an  apple,  as  in  Sir  Astley  Cooper's  case, 
already  alluded  to,  or  the  introduction  of  the  stomach-pump. 
Extraction  of  teeth,  even  in  the  most  skilful  hands,  has  been 
known  to  produce  the  accident,  which  has  also  been  caused 
by  the  ordinary  dental  operation  of  taking  a  model  of  the 
lower  jaw.  (Salter,  British  Journal  of  Dental  Science,  July, 
1871.)  Dr.  Guignier,  of  Montpellier,  has  also  reported 
{Abstract  of  Medical  Sciences,  vol.  ii.  1866)-  an  example  of 
complete  dislocation  occurring  during  the  laryngoscopic 
examination  of  a  lady,  aged  thirty-eiglit,  in"  whom  reduction 
was  readily  effected. 

The  pathology  of  dislocation  of  the  jaw  has  been  a  sub- 
ject of  considerable  discussion  and  investigation  from  the 
earliest  days  of  surgery  to  the  present  time,  and  various 
views  respecting  it  have  been  brought  forward  by  different 
authorities.  When  the  mouth  is  opened  to  its  fullest  extent, 
each  condyle  of  the  jaw  leaves  the  true  glenoid  cavity  and 
rests  against  the  articular  eminence  and  the  inter-articular 
fibro-cartilage,  which  is  drawn  forward  by  the  pterygoideus 
externus,  the  same  muscle  which  advances  the  jaw  itself. 
The  articular  eminence  is  covered  by  articular  cartilage, 
and  by  the  synovial  membrane  reflected  between  it  and  the 
cartilage,  and  a  second  synovial  membrane  being  placed 
betM'een  tlie  cartilage  and  the  condyle  of  the  jaw,  the 
necessary  freedom  of  movement  is  insured.  A  cavity  is 
thus  left  immediately  behind  the  condyle,  which  can  be 
readily  felt  in  tlie  healthy  living  subject,  and  which  is  only 
exaggerated  in  cases  of  dislocation.  When  the  jaw  is  in 
this  position,  but  a  very  slight  force  is  needed  to  carry  the 
condyle  over  the  articular  eminence  and  produce  a  disloca- 
tion, and  this  is  brought  about,  either  by  a  force  applied  to 
the  chin,  when,  owing  to  the  length  of  the  lever,  the  result 
is  readily  induced ;  or  by  a  spasmodic  contraction  of  the 
external  pterygoid  muscles,  which,  as  has  been  stated,  are 


MECHANISM  OF   DISLOCATION.  85 

already  in  action.  The  lateral  ligaments  of  the  joints  have 
no  power  to  check  this,  and  the  few  fibres  which  surround 
the  synovial  membrane  and  form  a  loose  capsule  are  easily 
stretched,  but  never  tear.  The  accompanying  illustration 
from    Sir   Astley  C  coper's  work   on  "  Dislocations,"  shows 

Fig.  39. 


the  position  of  the  bone  at  this  period,  but  is  wanting  in 
the  ligaments  and  inter-articular  cartilage,  which  latter  is 
ordinarily  carried  forward  with  the  condyle.  Immediately 
that  the  condyles  are  dislocated  the  masseter  and  internal 
pterygoid  muscles  contract,  and  draw  the  jaw  forwards  and 
upwards  so  as  to  produce  the  projection  of  the  chin  charac- 
teristic of  the  accident.  This  last  muscular  action  was 
originally  described  by  Petit,  and  has  been  denied ;  but  has 
recently  been  confirmed  by  Heinlezn  and  Busch,  who  found 
experimentally  on  the  dead  body,  that  by  replacing  the 
muscles  by  india-rubber  bands  acting  in  the  same  direction 
as  the  muscles,  the  luxation  could  be  invariably  maintained 
and  the  characteristic  deformity  produced. 

Both  Maisonneuve  {L' Union  Mediccde,  1863)  and  Otto 
Weber  (02?.  cit^,  have  experimented  upon  the  dead  body, 
and  have  succeeded  in  producing  dislocation  of  the  jaw  by 
imitating  the  three  movements  already  described,  when  the 
following  is  the  condition  of  the  parts  found  upon  dissec- 
tion : — The  condyles  are  in  front  of  the  root  of  the  zygoma, 
the  coronoid  processes  are  completely  surrounded  by  the 


86 


DISLOCATION   OF   THE   JAW. 


tendons  of  the  temporal  muscles,  and  are  quite  below,  and 
scarcely  ever  touch  the  malar  bone.  The  capsular  ligament 
is  tense,  but  not  ruptured  ;  the  external  lateral  ligament  is 
tense,  and  passes  from  behind  forwards  instead  of  from  be- 
fore backwards ;  the  internal  lateral  and  stylo-maxillary 
ligaments  are  stretched,  and  this  is  increased  by  raising  the 
chin.  The  inter-articular  fibro- cartilages  are  attached  to  and 
follow  the  motions  of  the  condyles.  According  to  Maison- 
neuve,  the  temporal  muscles  are  only  stretched ;  but  Weber 
says  that  some  of  the  fibres  are  usually  torn  off  the  coronoid 
process. 

The  fixation  of  the  dislocated  jaw  has  received  a  different 
explanation,  and  has  been  attributed  to  the  catching  of  the 
coronoid  process  against  the  malar  bone,  or  the  malar  pro- 
cess of  the  superior  maxilla.  This  view  was  originally  main- 
tained by  Fabricius  ab  Aquapendente,  by  Monro,  and  more 
recently  by  Nelaton  (Ecvm  Mcdico-Chirunjiccdc,  tom.  vi.}, 
who  is  followed  by  Malgaigne  in  his  treatise  on  "  Disloca- 


FiG.  40. 


tions"   (1855).      Ncilaton  maintains  that  in  his  experiments 
on  the  dead  body  he  constantly  found  the  coronoid  process 


MEGHAN rSM   OF   DISLOCATION. 


87 


fixed  against  the  malar  bone  ;  and  he  appeals  also  to  a 
unique  preparation  of  a  pathological  dislocation  which  he 
dissected  and  presented  to  the  Musee  Dupuytren.  The 
accompanying  illustration  (fig.  40),  reduced  from  Malgaigne's 
Atlas,  is  from  the  preparation  in  question.  The  coronoid 
process  in  this  certainly  touches  the  malar  bone,  and  the 
relations  of  the  inter-articular  cartilage  and  external  lateral 
ligaments  are  well  seen. 

Eibes  and  Monteggia  agree  with  Maisonneuve  and  Weber 
in  believing  that  in  most  jaws  the  coronoid  process  is  not 
long  enough  to  reach  the  malar  bone ;  and  the  last-named 
author  mentions  that  Eoser  was  unable  to  reduce  an  old  dis- 
location of  eight  weeks'  standing,  even  after  cutting  through 
both  coronoid  processes  from  within  the  mouth  by  means  of 
bone  forceps.  From  experiments  I  have  myself  instituted, 
I  believe  the  view  of  Maisonneuve  and  Weber  to  be  correct 
— viz.,  that  the  coronoid  jDrocess  does  not  become  fixed 
against  the  malar  bone.  In  the  macerated  skull  it  is  easy  to 
dislocate  the  condyle  so  far  in  front  of  the  articular  eminence 

Fig.  41. 


as  to  cause  the  coronoid  process  to  be   hooked   against  the 
malar  bone ;  but  this  is  by  no  means  easy  on  the  subject,  even 


88 


DISLOCATION   OF   THE  JAW. 


when  the  parts  are  dissected^  and  can  only  be  accomplished 
by  tearing  the  structures  of  the  joint  very  considerably. 
Besides,  the  position  the  jaw  assumes  when  the  condyles 
are  so  driven  forward,  is  not  that  of  the  ordinary  form  of 
dislocation,  the  jaws  being  too  widely  separated,  and  the 
chin  drawn  back  instead  of  being  advanced.  Were  the 
coronoid  processes  fixed  against  the  malar  bones,  it  would 
be  impracticable  to  effect  a  reduction  by  elevating  the  chin, 
as  is  frequently  done  ;  and,  moreover,  the  gradual  improve- 
ment noticed  in  old-standing  cases  of  dislocation  would  be 
impossible. 

A  preparation,  illustrating  the  anatomy  of  dislocation, 
was  dissected  for  me  by  my  friend  Mr.  Marcus  Beck, 
and  from  one  side  of  it  the  drawing  (fig.  41)  was  made. 

Symptoms  of  Dislocation. — When  the  dislocation  is  bi- 
lateral, the  deformity  is  so  evident  as  at  once  to  attract 

Fig.  42. 


attention.  The  mouth  is  open  and  the  jaw  fixed,  with  the 
lower  teeth  carried  beyond  those  of  the  upper  jaw,  as  seen 
in  fig.  42,  from  Fergusson.  Speech  and  deglutition  are  much 
interfered  with,  since  the  lips  cannot  be  approximated  ;  and. 


SYMPTOMS   OF   DISLOCATION. 


89 


for  the  same  reason,  the  saliva  dribbles  from  the  mouth. 
On  examining  the  neighbourhood  of  the  temporo-maxillary 
joint,  a  distinct  and  unusual  hollow  will  be  seen  immedi- 
ately in  front  of  the  ear,  and  the  condyle  may  be  both  seen 
and  felt  in  front  of  this.  The  coronoid  process  forms  a 
projection  immediately  behind  and  below  the  malar  bone, 
and  may  be  readily  felt  in  its  abnormal  position  from  the 
mouth.  The  masseter  is  firmly  contracted  and  strongly 
prominent.  E.  W.  Smith,  in  his  work  on  "  Fractures  and 
Dislocations,"  has  also  specially  called  attention  to  a  promi- 
nence immediately  above  the  zygoma,  which  has  not  been 
usually  described,  and  which  he  believes  is  due  to  the  condyle 
pressing  forward  and   stretching  the  posterior  fibres  of  the 

Fig.  43. 


temporal  muscle,  but  which  I  believe  to  be  caused  by  their 
spasmodic  contraction.  The  accompanying  drawing  (fig.  43), 
taken,  by  permission,  from  the  work  referred  to,  illustrates 
both  these  points. 


90  DISLOCATION   OF   THE   JAW. 

In  dislocation  of  one  condyle  only  the  signs  are  less 
manifest,  and  may  possibly  be  overlooked  or  misinterpreted. 
The  chin  is  usually  directed  towards  the  sound  side  instead 
of  toward  the  injured  side,  as  is  the  case  in  fracture  of 
the  neck  of  the  bone ;  the  hollow  in  front  of  the  ear  is 
equally  visible  in  this  as  in  the  double  form  of  dislocation, 
and  speech  and  deglutition  are  similarly  to  some  degree 
interfered  with.  The  obviousness  of  the  direction  of  the 
chin  to  one  side  will  depend  in  some  degree  upon  the 
original  prominence  of  that  feature  in  the  individual,  and 
too  much  stress  must  not  be  laid  upon  the  symptom  :  thus 
Hey,  in  his  "Practical  Observations  in  Surgery"  (1814), 
remarks — "  One  would  expect,  from  a  consideration  of  the 
structure  of  the  parts,  and  from  the  description  given  in 
systems  of  surgery,  that  tlie  chin  should  be  evidently  turned 
towards  the  opposite  side :  but  I  liave  repeatedly  seen  the 
disease  (accident)  where  I  could  discern  no  alteration  in  the 
position  of  the  chin.  The  symptom  which  I  have  found  to 
be  the  best  guide  in  this  case  is,  a  small  hollow  which  may 
be  felt  behind  the  condyle  that  is  dislocated,  wdiich  does  not 
subsist  on  the  sound  side."  R.  W.  Smith  also  mentions 
that,  in  a  case  of  luxation  of  the  right  condyle,  he  had  seen 
the  efforts  at  reduction  applied  to  the  left  side. 

Old-standing  Dislocations. — From  various  causes  disloca- 
tions of  the  jaw  have  been  from  time  to  time  overlooked, 
and  have  not  been  brought  under  the  notice  of  the  surgeon 
for  weeks  or  even  months  after  the  accident.  Thus  R.  W. 
Smith  (piJ.  cit.)  narrates  the  case  of  a  woman  who  dislocated 
her  jaw  in  an  epilej^tic  fit,  whilst  an  inmate  of  one  of  the 
Dublin  hospitals,  but,  the  accident  escaping  notice,  the  bone 
remained  unreduced.  The  drawing  in  Mr.  Smith's  work 
represents  the  condition  of  the  patient  one  year  after  the 
accident,  and  it  is  to  be  remarked  that  though  the  signs  of 
dislocation  are  sufficiently  obvious  in  the  hollow  in  front  of 
the  ear  and  the  projection  of  the  chin,  yet  that  the  patient 
was  able  to  close  the  lips  so  as  to  retain  the  saliva  and 
speak  intelligibly,  but  was  able  to  open  the  mouth  only 
to  a  limited  extent. 


OLD-STANDING   DISLOCATIONS. 


91 


Mr.  John  Coiiper  has  recorded  an  equally  interesting 
case  in  the  London  Hospital  Reports,  vol.  i.  p.  263. 
More  than  three  months  before,  the  patient  had  dislocated 
her  jaw  bilaterally  (for  the  second  time)  whilst  yawning, 
and  when  seen,  she  presented  the  appearance  shown  in  the 
illustration  (fig.  44),  for  which  I  am  indebted  to  the  editors 
of  the  Reports.  Mr.  Couper  found  that  the  jaw  had  re- 
covered a  certain  amount  of  mobility,  so  that  the  incisors  of 
the  two  jaws  could  be  approximated  to  within  an  inch,  and 

Fig.  44. 


separated  to  an  inch  and  a  half,  the  molar  teeth  being 
nearly  in  contact  during  extreme  closure.  The  chin  was 
depressed  and  carried  forward,  and  the  hollow  in  front  of 
the  ear  was  well  marked.  The  patient's  utterance  was 
slightly,  if  at  all,  impaired,  and  the  labial  consonants  were 
pronounced  as  distinctly  as  other  sounds,  and  the  saliva  was 
retained,     Mr.   Couper  made   attempts,   under   chloroform, 


92  DISLOCATION   OF   THE   JAW. 

Loth  with  levers  and  forceps,  to  reduce  the  dislocation,  but 
without  success,  but  the  effect  of  the  operation  was  to  in- 
crease the  range  of  motion  of  the  jaw. 

A  second  case  of  old  double  dislocation  of  the  jaw  oc- 
curred in  the  London  Hospital  in  the  year  following  Mr. 
Couper's,  and,  being  of  only  two  months'  standing,  was  re- 
duced with  some  little  difficulty  by  Mr.  Hutchinson,  who 
says  {London  Hospital  Beports,  vol.  ii.  p.  33)  :  "  The  woman 
was  unable  to  shut  her  mouth,  and  her  chin  struck  forward, 
giving  her  face  an  awkward,  lantern-jawed  expression  ;  but 
there  was  no  wide  gaping  and  she  could  easily  shut  her  lips." 
The  readiness  with  which  the  accident  may  be  overlooked 
is  illustrated  by  the  concluding  observation  of  Mr.  Hutchin- 
son— "We  had  fancied  at  first  that  tliere  was  but  little 
facial  deformity,  but  this  impression  was  corrected  at  once 
when  we  had  her  natural  expression  before  us  by  way  of 
contrast.'^ 

Probably  the  longest  period  which  has  elapsed  after  the 
accident  and  has  been  followed  by  successful  reduction  is 
four  months,  and  this  occuiTcd  in  a  woman  in  wdiom  Mr. 
l*ollock  reduced  the  dislocation,  by  inserting  wedges  between 
the  molar  teeth  and  drawing  up  the  chin  by  means  of  a 
strap-tourniquet  passed  over  the  head.  {St.  George's 
Hospital  Reports,  vol.  i.). 

Other  examples  of  the  successful  reduction  of  old-standing 
dislocations  have  been  from  time  to  time  recorded.  Thus  Sir 
Astley  Cooper  ("  Fractures  and  Dislocations")  gives  a  case  in 
which  Mr.  Morley  reduced  a  dislocation  after  a  month  and 
five  days.  Stromeyer  had  a  similar  case.  Spat  was  successful 
in  a  case  fifty -eight  days  old ;  Demarquay  in  one  of  eighty- 
tliree  days  (Weber,  op.  cit.),  and  Donovan  in  one  of  even 
ninety-eight  days  {DuUin  Medical  Press,  May,  1842). 

Rare  Forms  of  Dislocation. — A  few  cases  of  rare  forms  of 
dislocation  with  fracture  have  been  described.  The  cases 
recorded  by  Eobert  of  dislocation  outwards  with  fracture  on 
the  opposite  side,  and  by  Mr.  Croker  King  and  Mr.  Gun- 
ning of  New  York,  of  dislocation  outwards  and  backwards 
with  fracture  of  the  symphysis,  have  been  akeady  referred 


TEEATMENT  OF  DISLOCATION.  93 

to  under  the  head  of  "  fracture  complicated  by  dislocation." 
It  miglit  be  supposed  from  the  anatomy  of  the  parts  tha-t 
dislocation  backwards  would  be  impossible  without  fracture 
of  the  front  wall  of  the  meatus  auditorius  externus  or  of 
the  glenoid  cavity,  and  the  specimen  in  St.  George's  Museum 
(i.  28)  is  an  instance  in  point.  In  Mr.  King's  case  there 
can  be  little  doubt  that  there  was  some  injury  to  the  meatus, 
from  the  hoemorrhage  which  occurred. 

Congenital  Dislocations. — Cases  of  congenital  dislocation 
of  the  lower  jaw,  with  more  or  less  malformation,  have  been 
recorded  by  Guerin  [Gazette  MMicale  de  Paris,  1841)  and 
E.  W.  Smith  (''  On  Fractures  in  the  Vicinity  of  Joints'^),  who 
gives  alaborate  drawings  of  the  dissections  of  the  case. 
Mention  may  be  made  also  of  the  cases  of  congenital  small- 
ness  and  arrest  of  development  recorded  respectively  by 
Langenbeck  {Archiv  filr  Klin.  Chir.,  i.)  by  Mr.  Canton  {Patlio- 
logical  Society's  Transactions,  vol.  xii.),  and  Dr.  Ogston's 
elaborate  paper  on  "  Congenital  Malformation  of  the  Lower 
Jaw,"  {Glasgoio  Medical  Journal,  1875) ;  but  these  subjects 
do  not  properly  come  within  the  scope  of  this  work. 

Suh-hixation  of  the  jaw  was  first  described  by  Sir  Astley 
Cooper,  and  has  been  generally  recognised  by  surgical  writers 
since  his  time.  It  will  be  described  in  the  chapter  on 
diseases  of  the  temporo-m axillary  joint. 

Treatment  of  Dislocation. — Although  ordinarily  requiring 
the  assistance  of  the  surgeon,  dislocations  of  the  jaw  have 
been  known  to  become  reduced  spontaneously,  or  with  the 
aid  of  the  patient  alone.  Nelaton  mentions  a  case  of  spon- 
taneous reduction  occurring  in  his  own  practice ;  and  Sir 
Astley  Cooper  narrates  the  case  of  a  lady  who  reduced  a 
dislocation  of  one  side,  induced  l>y  sea-sickness,  with  the  help 
of  an  oyster-knife.  Levison  also  gives  the  case  of  an  old 
man  who,  suffering  from  recurring  dislocation,  especially 
when  waking  from  sleep,  "  would  pull  his  jaw  and  press  it 
backwards,  when,  after  about  half  an  hour's  work,  bang  it 
seemed  to  go,  and  all  was  right  again." 

In  recent  cases  of  dislocation,  reduction  may  usually  be 
accomplished  with  facility  by  various  methods  of  manipula- 


94  DISLOCATION   OF   THE   JAW. 

tion,  but  cases  of  long  standing  may  require  some  instru- 
mental assistance.  The  simplest  mode  is  for  the  head  of 
the  patient  to  be  held  firmly  against  the  breast  of  an 
assistant,  while  the  operator,  having  protected  his  thumbs 
with  lint  or  a  towel  twisted  round  tliem,  presses  them  as  far 
back  as  possible  upon  the  molar  teeth,  grasping  the  jaw  at 
the  same  time  with  his  fingers.  Pressure  is  then  made 
downwards  and  backwards,  so  as  to  free  the  condyles  from 
the  articular  eminence,  and  as  soon  as  this  is  done  the  chin 
is  elevated  and  the  condyles  slip  into  place.  This  plan  may 
be  advantageously  modified  by  reducing  the  condyles  suc- 
cessively though  at  the  same  operation,  care  being  taken 
that  the  condyle  first  reduced  is  not  again  dislocated,  as  has 
happened  more  than  once.  The  proceeding  is  thus  ren- 
dered easier,  because  one  condyle  forms  a  point  of  support 
or  fulcrum  for  the  other,  so  that  the  entire  jaw  is  used  as  a 
lever,  instead  of  the  thumbs  forming  the  fulcra,  as  in  the 
other  method.  This  latter  method  also  obviates  the  danger 
of  the  jaw  suddenly  closing  uj)on  the  thumbs,  though  tliis 
is  probably  somewhat  exaggerated. 

Sir  Astley  Cooper  recommended  the  introduction  of  two 
corks  (or  one  in  the  case  of  single  dislocation)  between  the 
molar  teeth  to  act  as  fulcra,  the  chin  being  then  drawn 
upwards  ;  and  narrates  the  case  of  a  madman,  where,  for  his 
own  safety,  he  used  two  table-forks  with  a  handkerchief 
wrapped  round  them  to  act  as  fulcra.  The  same  method 
was  originally  employed  by  Ambrose  Pare,  who  used 
wedges  of  wood  instead  of  cork,  and  his  example  has  been 
followed  by  numerous  surgeons.  Mr.  Pollock  employed 
this  method  successfully  in  1866,  in  a  case  of  dislocation  of 
four  months'  standing  ;  a  gag  being  placed  between  the 
molar  teeth,  and  the  strap  of  an  ordinary  tourniquet  being 
applied  round  the  head  and  beneath  the  jaw,  so  that  the 
screw  might  exert  its  power  upon  the  dislocated  bone. 
(St.  Georr/e's  Hosjntal  Reports,  vol.  i.). 

Instead  of  mere  fulcra  having  been  inserted  Ijetween  the 
molar  teeth,  levers  liave  been  employed  to  depress  the  lower 
jaw  in  cases  of  difficulty;  thus  Sir  Astley  Cooper  narrates 


stromeyer's  forceps.  95 

that  Mr.  Fox,  the  dentist^  "  placed  a  piece  of  wood  a  foot 
long  upon  the  molar  tooth  of  one  side,  and  raising  it  at  the 
part  at  which  he  held  it,  depressed  the  point  at  the  jaw  on 
that  side,  and  succeeded  in  reducing  the  condyle.  He  then 
did  the  same  on  the  other  side,  and  thus  replaced  the  bone." 
Here,  of  course,  the  upper  jaw  formed  the  fulcrum,  and  the 
advantage  of  acting  upon  one  condyle  at  a  time  is  seen. 
Tliis  method  is  not  invariably  successful,  however,  for  in  the 
case  of  old  dislocation  under  Mr.  Couper's  care,  already 
related,  that  gentleman  employed  levers  of  pine  wood  six 
inches  long  without  success. 

A  more  powerful  leverage  action  is  obtained  by  the  for- 
ceps invented  by  Stromeyer,  which  is  shown  in  the  illustra- 
tion (fig.  45).     The  forceps  consists  of  two  blades  expanded 

Fig.  45. 


at  the  extremities,  so  as  to  fit  pretty  accurately  the  dental 
arches  of  the  upper  and  lower  jaws,  and  covered  with  leather. 
A  spring  between  the  handles  tends  to  keep  the  blades 
closed,  and  a  screw  and  nut,  acting  upon  the  handles,  is 
able  to  close  them  so  as  to  make  the  blades  diverge  forcibly ; 
at  the  same  time  a  movable  pin  loosens  this,  so  that  the  blades 
may  be  closed  again  the  moment  they  have  done  their  work. 
The  blades  being  closed,  and  introduced  between  the  teeth 
as  far  as  possible,  are  then  separated  by  means  of  the  nut 
and  screw,  until  the  condyles  are  disentangled  from  the 
articular  eminences,  when,  being  suddenly  closed,  they  are 
withdrawn,  an  assistant  at  the  same  time  pressing  the  jaw 
backwards,  so  as  to  bring  the  condyles  into  the  glenoid 
cavities.  In  this  way  Stromeyer  reduced  a  dislocation  of 
thirty-five  days'  standing. 

Nekton,  whose  view  with  regard  to  the  locking  of  the 
coronoid  processes  against  the  malar  bones  has  been  already 


96  DISLOCATION   OF   THE  JAW. 

referred  to,  advocates  acting  directly  upon  these  processes* 
in  order  to  force  them  and  the  condyles  backwards.  The 
surgeon  may  stand  in  front  of  the  patient,  and,  with  his 
thumbs  pressing  against  the  coronoid  processes,  within  or 
without  the  mouth,  may  grasp  the  mastoid  processes  with  his 
fingers,  and  thus  have  a  firm  point  cVappui  to  act  from ;  or, 
sitting  behind  the  patient,  he  may  place  his  thumbs  on  the 
nape  of  the  neck,  and  endeavour  to  draw  the  jaw  backwards 
with  his  fingers. 

Maisonneuve,  though  differing  from  Nelaton  with  regard 
to  the  pathology  of  the  affection,  agrees  with  him  in  the 
propriety  of  acting  upon  the  coronoid  processes.  The  fol- 
lowing were  the  conclusions  he  arrived  at  from  numerous 
experiments  on  the  dead  body  : — Blows  ■  on  the  cheeks  or 
chin  (which  have  been  recommended  in  bygone  days)  were 
useless;  pressure  with  the  thumbs  on  the  back  teeth,  com- 
bined with  elevation  of  the  chin,  succeeded  only  a  few  times  ; 
depression  of  the  chin  at  the  same  time  that  the  thumbs 
pressed  away  the  masseters  from  the  interior  of  the  mouth 
was  rather  more  successful ;  depression  of  the  chin  and 
pressure  on  the  coronoid  processes  from  before  backwards, 
with  the  thumbs  in  the  mouth,  effected  reduction  constantly 
and  with  ease. 

In  November,  1883,  Mr.  Golding  Bird  brought  before  the 
Clinical  Society  a  man  aged  twenty-two,  in  whom  an  un- 
reduced dislocation  of  both  condyles  had  existed  for  eighteen 
weeks.  After  breaking  dow^n  adhesions  Mr.  Bird  succeeded 
in  reducing  the  right  condyle,  and  suTjsequently  the  left,  by 
Ndlaton's  method  of  pressing  directly  upon  tlie  coronoid 
processes,  followed  by  drawing  up  the  chin. 

In  all  cases  of  dislocation  the  administration  of  chloro- 
form will  facilitate  the  reduction,  but  it  is  not  necessary  in 
recent  cases.  In  old-standing  cases  it  should  invariably  be 
had  recourse  to,  since  the  operation  will  necessarily  be  botli 
painful  and  prolonged,  in  consequence  of  the  formation  of 
fibrous  adhesions. 

When  reduction  has  been  effected,  the  precaution  should 
be  taken  to  limit  the  movements  of  the  jaw  for  a  week  or 


TREATMENT    AFTER    REDUCITTON.  97 

two,  by  tliG  use,  of  the  four-tailed  Ijaiidagc  used  in  cases  of 
fracture  of  the  jaw.  In  individuals  lia])le  to  recurring  dis- 
location of  the  jaw  (like  the  woman  mentioned  hy  Putegnat, 
whose  jaw  was  dislocated  once  a  month),  some  elastic  support 
for  the  chin  should  be  employed,  and  care  be  taken  not  to 
open  the  mouth  too  widely. 

In  the  Lancet  of  April  14,  1883,  Mr.  Pughe,  of  Liverpool, 
has  reported  the  case  of  a  boy  of  four  years,  in  whom  the 
condyle  was  dislocated  by  a  blow  on  the  chin  two  years 
before,  and  in  whom  anchylosis  between  the  condyle  and 
the  zygoma  had  taken  place,  causing  complete  closure  of 
the  jaws.  Mr.  Pughe  resected  the  condyle,  with  the  result 
that  the  patient  could  open  his  mouth  to  the  extent  of  an 
inch,  but  had  no  lateral  movement. 


H 


98 


CHAPTEE  VII. 

INFLAMMATION — ABSCESS PERIOSTITIS. 

Inflammation  of  the  periosteum  leading  to  necrosis,  and 
inflammation  in  connexion  with  carious  teetli  leading  to 
abscess,  appear  to  be  common  to  both  jaws,  but  there  is  a 
form  of  inflammation  to  which  the  lower  jaw  alone  is  sub- 
ject, which  requires  notice.  The  inferior  maxilla  differs 
from  the  superior  in  consisting  of  two  plates  of  compact 
tissue  (of  which  the  outer  is  the  thinner)  separated  by  can- 
cellous bone,  through  which  runs  a  canal  for  the  passage  of 
the  inferior  dental  nerve  and  vessels,  each  of  which  gives 
an  offset  to  each  dental  fang.  When  from  the  irritation  of 
unsound  teeth  inflammation  is  excited,  it  rapidly  spreads 
up  the  jaw,  leading  in  a  few  hours  to  an  amount  of  effusion 
into  the  cancellous  structure  which  distends  it,  and  forces  out 
the  external  plate  of  the  bone.  This  effusion,  as  I  have  had 
the  opportunity  of  observing  in  my  own  person,  is  at  first  of 
discoloured  serum,  which  by  pressure  on  the  jaw  can  be 
made  to  exude  by  the  side  of,  or  through,  the  hollow  tooth 
which  was  the  original  cause  of  the  mischief.  If  the  source 
of  irritation  be  allow^ed  to  remain,  plastic  effusion  now  takes 
place,  leading  to  the  formation  of  a  distinct  tumour,  usually 
in  the  neighbourhood  of  the  off'ending  tooth.  This  is  slowly 
absorbed  on  the  early  removal  of  the  tooth,  but  if  tlie  irrita- 
tion be  allowed  to  continue,  the  effusion  will  become  organized 
into  fibrous  tissue,  and  a  very  serious  affection  may  thus  be 
produced.  From  an  attentive  examination  of  numerous 
examples  of  fibrous  tumour  of  the  lower  jaw,  botli  before  and 
after  removal,  I  feel  sure  that  the  majority  originate  in  the 
manner  licre  described. 


ABSCESS.  99 

I  had  in  the  summer  of  1807  a  patient  under  ni}'  care — 
a  boy  aged  fourteen — who  was  suffering  from  an  enlarge- 
ment of  the  lower  jaw,  due  to  an  expansion  of  its  wall  by  a 
growth  evidently  connected  with  a  carious  permanent  first 
molar  tooth.     I  had  the  peccant  tooth  extracted,  but  the 
enlargement  of  the  jaw  continued.     In  August  some  sup- 
puration occurred,  and  an  abscess  broke  behind  the  angle  of 
the  jaw,  but  this  soon  healed,  and  in  ISTovember  he   was 
perfectly    free    from    pain   and    able    to    open    the   mouth 
thoroughly.     I  was  anxious  to  perforate  the  jaw  from  the 
mouth  so  as  to  give  exit  to  any  fluid  contained  in  it  and 
extract  any  solid  material  which  might  exist,  but  the  parents 
would  not  consent  to  any  surgical  interference.     The  face 
had   in   May,   1868,   considerably  diminished    in   size,   but 
there   was  still  a  difference  between  the  two  sides;    two 
years  later,  however,  I  could  detect  no   difference  between 
them.     In  a  little  girl  of  seven,  also,  whom  I  saw  in  1872, 
with  great  enlargement  of  the  right  side  of  the  lower  jaw,  in 
six  years  the  part  had  resumed  its  natural  shape.     Stanley 
in  his  work  on  the  Bones  (p.  20)  says,  "  I  believe  that  a 
Ijone  once  enlarged  by  the  expansion  of  its  tissue  will  per- 
manently remain  so  ;"  but  this  rule  does  not  hold  good  with 
the  lower  jaw,  which  bone  can  most  certainly  nndergo  very 
considerable  expansion  and  yet  recover  its  original  form. 

Abscess. — Inflammation,  the  result  of  diseased  teeth,  may 
lead  to  suppuration  and  abscess,  and  this  may  occur  either 
as  the  ordinary  Alveolar  Abscess  or  Gum-boil,  or  as  an 
abscess  in  the  substance  of  the  jaw,  either  upper  or  lower, 
which  is  a  more  serious  affection.  In  ordinary  Alveolar 
Abscess  (jxtmlis)  the  mischief  begins  at  the  apex  of  the  fang 
of  a  carious  tooth  by  an  effusion  of  plastic  material^  around 
which,  according  to  Salter  ("  System  of  Surgery,"  vol.  ii.), 
a  little  cavity  is  formed  by  the  absorption  of  the  alveolus, 
often  accompanied  by  some  amount  of  absorption  of  the  fang 
itself.  A  portion  of  this  lymph  becomes  converted  into 
pus,  and  the  remainder  forms  a  kind  of  sac  around  it,  so 
that  it  occasionally  happens  that,  on  the  extraction  of  the 
peccant  tooth,  the  sac  and  abscess  are  brought  away  with  it, 

H  2 


1 00  ABSCESS. 

So  soon  as  iiiattei'  is  actually  formed,  rapid  absorption  of  the 
surrounding  bone  takes  place,  and  the  pus  makes  for  the 
surface,  finding  an  exit  either  at  the  side  of  the  tooth,  or  b}" 
perforating  the  socket  and  burrowing  in  the  soft  tissues. 
The  direction  which  the  pus  of  an  alveolar  abscess  may  take 
is  very  variable.  According  to  Salter  the  commonest  position 
for  the  matter  to  point  is  "on  the  outer  surface  of  the  jaw  at 
a  point  corresponding,  as  nearly  horizontally  as  may  be,  with 
the  extremity  of  the  fang  of  the  affected  tooth,  and  jncrcing 
the  gum  itnthin  the  month."  But  the  matter  may  find  its 
way  on  to  the  face,  beneath  the  cliin,  or  into  the  antrum, 
and,  according  to  Tomes  ("  Dental  Surgery"),  "  collections  of 
matter,  formed  about  the  wisdom  teeth,  pass  between  the 
muscles  and  bone  and  escajie  at  the  angle  of  the  jaw."  Both 
Tomes  and  Saltei-  mention  the  tendency  of  pus,  derived  from 
an  upper  incisor  tooth,  to  burrow  between  the  bone  and 
periosteum  of  the  hard  palate  and  open  upon  the  surface  of 
the  soft  palate.  The  former  also  states  that  occasionally  the 
pus  separates  the  periosteum  from  one  side  of  the  hard 
palate,  and  forces  it  down  to  a  level  with  the  teeth. 

Abscess  connected  with  the  upper  incisor  teeth  may  also 
point  within  the  nostrils  by  small  orifices  presenting  little 
teat-like  elevations,  which  will  be  at  once  detected  on  a 
careful  examination  of  the  nostrils.  The  patient's  attention 
will  have  probably  been  directed  to  the  occasional  discharge 
of  pus  from  the  nose,  and  the  case  may,  without  care,  be 
erroneously  treated  as  one  of  ozfena. 

The  early  symptoms  of  alveolar  abscess  are  those  of 
inflammation  of  the  periosteum  lining  the  alveolus,  and  of 
the  periodontal  membrane  of  the  tooth  itself.  There  is  a 
dull,  obscure  pain,  relieved  by  biting  upon  the  tooth,  which 
appears  to  be  raised  slightly  from  the  socket.  The  pain 
soon  becomes  of  an  acute,  throbbing  kind,  and  the  consti- 
tutional symptoms  are  occasionally  severe,  amounting  to 
liigh  fever  and  delirium.  The  local  symi^toms  are  swelling 
and  tenderness  of  the  gum,  and,  according  to  Tomes,  an 
early  but  evanescent  symptom  is  a  well-defined  red  ring 
encircling  the  neck  of  the  tooth.     The  jaw  becomes  rapidly 


TREATMENT  OF  INFLAMMATION.        101 

swollen  and  the  face  consetiuently  distorted,  and  the  acute 
symptoms  continue  until  the  pus  has  found  an  exit,  and 
then  as  rapidly  subside. 

Treatment. — In  the  early  stage,  if  the  affected  tooth  has 
been  recently  stopped,  and  more  particularly  if  the  nerve- 
pulp  has  been  destroyed  with  arsenic,  the  stopping  should 
be  inmiediately  removed,  or  a  hole  drilled  into  the  pulp- 
cavity  through  the  side  of  the  tooth,  so  as  to  give  exit  to 
any  accumulated  fluid.  (See  paper  on  Ehizodontresis, 
by  Mr.  Hulme  :  British  Journal  of  Dental  Science,  April, 
1865.) 

Where  there  is  no  obvious  exciting  cause  for  the  inflam- 
mation, the  application  of  one  or  two  leeches  to  the  gum 
through  a  leech-tube,  and  the  subsequent  fomentation  of 
the  part  by  means  of  hot  water  held  in  the  mouth,  may  give 
relief;  but  if  this  is  not  the  case,  or  if  there  be  an  obvious 
local  source  of  irritation,  extraction  of  the  tooth,  or  stump 
of  a  tooth,  should  be  immediately  performed.  There  is  a 
popular  notion,  which  has  received  some  support  at  the 
hands  of  certain  members  of  the  profession,  that  extraction 
of  a  tooth  must  not  be  performed  during  the  stage  of  active 
inflammation  of  the  alveolus.  I  know  of  no  foundation  for 
this  statement,  which  is  entirely  devoid  of  truth,  and  yet  it 
has  formed  the  ground  for  an  action  against  an  eminent 
member  of  the  dental  profession.  It  may  be  well,  there- 
fore, to  put  on  record  the  statement  of  the  President  of  the 
"  Association  of  Surgeons  practising  Dental  Surgery,^'  in 
answer  to  the  question,  "  Is  it  right  to  refuse  to  extract  a 
carious  and  aching  tooth  on  account  of  the  acuteness  of  the 
periosteal  and  maxillary  inflammation  which  its  presence 
has  excited  ?"  The  President  (Mr.  Cattlin,  F.E.C.S.J  "  was 
glad  that  Mr.  Owen  had  brought  under  discussion,  in  his 
practical  paper,  an  unskilful  kind  of  practice  which  greatly 
increased  human  suftering,  and  was  often  very  injurious  to 
the  patient  in  after-life.  It  was  the  erring  practice  of  some 
to  wait  until  the  inflammation  subsided  ;  Init  if  the  tooth 
be  retained,  the  swelling,  as  a  rule,  rapidly  extends  to 
adjoining  parts,  and  sometimes  causes   necrosis,  occasionally 


102  ABSCESS. 

iiitiltration  into  muscles,  restricting  the  movements  of  the 
jaw,  and  often  ending  in  abscess,  which,  bursting  externally, 
permanently  disfigures  the  face."  {Medical  Press  ami  Cir- 
cular, January  12,  1881.) 

When  matter  has  formed,  and  is  finding  a  precarious  exit 
by  the  side  of  the  tooth,  which  is  certainly  dead  and  will 
only  prove  a  source  of  irritation,  its  immediate  extraction  is 
the  best  practice.  But  when,  as  frequently  happens,  the 
matter  has  perforated  the.  alveolus,  and  passed  into  the  sub- 
stance of  the  gum  so  as  to  produce  an  elastic  fluctuating 
tumour  between  the  teeth  and  the  cheek,  a  free  incision 
into  it  is  the  best  and  only  mode  of  treatment ;  and  in 
these  cases,  if  the  hole  in  the  alveolus  is  suthciently  large 
to  give  free  exit  to  the  pus,  the  tooth  may  be  eventually 
saved.  I  know  of  no  reason  for  delaying  the  incision  until 
the  gum  has  become  distended  with  pus,  though  the  practice 
has  its  advocates.  So  soon  as  inflammatory  swelling  takes 
place,  an  incision  will  do  good  by  relieving  congestion  and 
giving  exit  to  exudations  ;  and  I  have  never  seen  reason  to 
regret  an  early  and  free  incision  in  such  cases.  A  sharp 
scalpel  or  small  bistoury  is  the  best  instrument  for  the 
operation,  the  ordinary  gum-lancet  being  unsuitable  and 
inconvenient  for  the  purpose,  and  no  damage  to  neighbouring 
parts  can  happen  if  the  edge  of  the  knife  is  directed  to- 
wards the  bone.  I  have  once  known  the  facial  artery 
wounded  from  within  the  cheek,  from  neglect  of  this  pre- 
caution. 

In  cases  of  abscess  arising  from  the  upper  incisor  teeth 
and  extending  along  the  palate,  a  free  and  early  incision  is 
even  more  necessary  than  in  the  ordinary  form  of  abscess, 
since  extensive  necrosis  and  exfoliation  of  the  hard  palate, 
with  consequent  perforation,  may  not  improbably  result 
from  the  delay.  The  same  rule  liolds  good  also  in  all  cases 
of  matter  pointing  within  the  cavity  of  the  mouth;  but 
where,  as  has  already  been  mentioned,  the  matter  shows  a 
tendency  to  point  on  the  skin  of  the  face  or  neck,  every 
means  should  be  taken  to  avert,  if  possible,  the  opening  in 
this  situation,  and  to  insure  an  exit  for   the  matter  within 


TREATMENT   OF    ABSCESS.  103 

the  mouth.  In  order  to  fufil  the  latter  indication,  which 
is  most  essential,  the  tooth  or  stump  which  has  been  the 
cause  of  the  mischief  should  be  immediately  extracted,  and 
a  deep  incision  made  through  the  gum  near  the  spot  where 
the  matter  points.  It  may  be  well  to  notice  here,  tliat  the 
cause  of  the  abscess  in  these  cases  is  not  unfrequently  over- 
looked, owing  to  the  distance  between  the  tooth  and  the 
point  where  the  matter  appears,  and  that,  in  all  cases  there- 
fore of  abscess  about  the  jaws  or  neck,  it  is  well  to  investi- 
gate carefully  the  state  of  the  mouth. 

On  two  occasions  I  have  known  death  result  from  a  low 
form  of  cellulitis  spreading  between  the  muscles  of  the 
neck  and  leading  to  oedema  of  the  larynx,  distinctly  trace- 
able to  neglected  alveolar  abscess,  in  patients  whose  consti- 
tution had  been  greatly  damaged  by  intemperance.  In  the 
first,  I  had  made  free  incisions  in  the  mouth  and  neck,  but 
oedema  giottidis  supervened  in  the  night  and  proved  fatal. 
In  the  second,  I  took  the  precaution  of  freely  scarifying  the 
mucous  membrane  of  tlie  throat,  but  here  again,  unfortu- 
nately, I  was  not  summoned  when  the  breathing  became 
urgent.  I  would  strongly  advise  in  a  similar  case  the  early 
performance  of  laryngotomy  as  a  safeguard,  in  addition  to 
free  incisions. 

No  greater  mistake  can  be  made  than  to  encourage  the 
pointing  of  an  alveolar  abscess  on  the  surface  of  the  skin  by 
poulticing.  During  the  early  and  acute  stage  of  the  inflam- 
mation, the  warmth  of  a  poultice  may  be  grateful  to  the 
patient,  and  if  applied  for  a  few  hours  will  do  no  harm, 
though  I  should  myself  greatly  prefer  the  application  of 
extract  of  belladonna  and  glycerine  in  equal  proportions  ; 
but  continued  poulticing  will  merely  lower  the  vitality  of 
the  part,  and  tend  to  the  very  result  which  is  to  be  avoided 
if  possible.  Even  when  the  skin  is  already  reddened  and 
adherent  to  the  bone,  its  breaking  may  be  avoided  (provided 
a  free  exit  for  the  discharge  of  matter  into  the  mouth  has 
been  secured)  by  painting  the  surface  with  flexile  collodion 
or  with  the  tincture  of  iodine,  all  warm  applications  being 
discarded. 


1 04  ABSCESS. 

Tlic;  sinuses  left  after  an  alveolar  abscess  has  burrowed 
through  the  integuments,  remain  open  so  long  as  the  cause 
of  irritation  is  untouched,  and  the  orihce  though  con- 
tracted never  closes,  being  surrounded  by  granulations  which 
sometimes  grow  to  a  large  size.  I  recentl}''  had  under  my 
care  a  girl  who  was  brought  to  me  for  the  supposed  growth 
of  a  horn  from  her  chin,  and  the  appearance  was  not  unlike 
one  of  the  horn-like  growths  of  cuticle  occasionally  met  with. 
It  proved  to  be  nothing  more  than  a  growth  of  epithelium 
on  the  top  of  long  granulations  around  a  fistulous  opening, 
due  to  the  presence  of  a  stump  in  the  lower  jaw,  the  bone 
having  been  perforated  by  the  abscess.  The  successful 
treatment  of  these  sinuses,  like  those  dependent  npon  the 
presence  of  dead  bone  elsewhere,  can  only  be  insured  by  the 
extraction  of  the  offending  tooth  or  stump.  In  these  cases 
the  fang  is  necrosed  and  forms  a  sequestTum  in  the  same 
way  as  a  jjiece  of  bone,  and  will  keep  up  irritation  so  long 
as  it  is  allowed  to  remain.  The  distance  from  the  jaw  at 
which  an  alveolar  abscess  may  occasionally  point  not  un- 
frecjuently  leads  to  mistakes  in  diagnosis  and  treatment, 
particularly  of  the  resulting  sinus.  I  have  on  several 
occasions  known  a  sinus,  at  some  distance  below  the  loAver 
jaw,  treated  by  injections  when  the  fang  of  a  tooth  Avas 
keeping  up  irritation,  and  Salter  has  seen  openings  an  inch 
below  the  clavicle  dependent  upon  the  same  cause.  I  have 
once  found  the  diseased  fang  so  deeply  buried  and  over- 
lapped by  the  neighbouring  teeth  that  it  could  only  be 
detected  by  careful  probing  from  the  mouth,  and  it  was 
necessary  to  remove  the  adjacent  tooth  in  order  to  reach  the 
cause  of  the  sinus. 

Abscess  may  form  in  the  substance  of  the  upper  or  lower 
jaw  as  a  consequence  of  decayed  teeth,  but  differing  from 
ordinary  alveolar  abscess  in  the  absence  of  any  tendency  to 
find  an  exit  by  the  socket  of  the  tootli.  In  the  upper  jaw 
this  affection  has  been  confounded  witli  the  so-called 
"  abscess  of  the  antrum,"  whicli  is  more  i^rojierly  an  em- 
pyema, and  which  will  be  subsequently  dis(jussed  ;  and  Otto 
Weber   {Alhjcmciiuji  und  sjjcciellcn   Chirurfjic,  iii.)  strongly 


A.B8CE,S8    OF    LOWER   JAW.  105 

iiuiiiitaiiis  that  abscess  may  form  in  the  wall  of  the  antrum, 
hut  perfectly  separated  from  it  both  by  the  periosteum 
and  the  mucous  membrane^  or  sometimes  by  a  plate  of 
bone. 

Abscess  in  the  substance  of  the  lower  jaw  has  been  more 
frequently  met  Avith  :  thus  Mr.  Annandale,  of  J^fewcastle,  met 
with  a  case  of  chronic  abscess  in  the  left  side  of  the  lower 
jaw  of  a  boy  aged  ten,  resulting  apparently  from  rei)eated 
blows  upon  the  part.  Owing  to  the  great  thickening  of  the 
bone  the  abscess  was  not  diagnosed,  and  tlie  half  of  the  jaw 
was  removed,  the  boy  making  a  good  recovery.  The  tumour 
was  of  the  size  of  an  llen^s  egg,  and  extended  from  the  first 
bicuspid  tooth  to  the  articulation.  On  section,  the  bone  was 
found  to  be  very  dense,  and  contained  a  cavity  of  the  size 
of  a  horse-bean,  filled  with  pus,  and  lined  by  a  distinct 
membrane  of  some  thickness.  (Edinhurgh  Medical  Journal, 
December,  1860.)  In  a  lady  whom  I  saw  with  Mr.  G. 
Bateman,  there  was  a  fluctuating  swelling  of  the  lower  jaw 
in  the  incisive  region,  from  which  I  evacuated  by  incision  a 
quantity  of  offensive  inspissated  pus,  a  "  residual  abscess" 
due  to  irritation  from  incisor  teeth  which  had  been  extracted 
some  time  before  I  saw  the  patient. 

Another  mode  in  which  abscess  may  be  formed  in  both 
the  upper  and  lower  jaws  is  by  the  sujjpuration  of  a 
"  dentigerous  cyst"  connected  with  non-developed  or  im- 
perfectly developed  teeth.  A  remarkable  case  of  this  kind 
is  reported  by  Weber  {pi).  cit.)  in  which  a  woman,  aged 
twenty-five,  shortly  after  the  partial  eruption  of  a  wisdom- 
tooth,  found  a  tumour  forming  on  the  left  side  of  the  jaw, 
which  in  a  year  extended  from  the  mental  foramen  to 
beyond  the  angle.  The  bone  gave  a  crackling  sound  when 
pressed  upon,  and  in  one  or  two  situations  appeared  to 
be  entirely  absorbed.  An  incision  was  made  over  it  and 
the  tissues  turned  aside,  and  on  opening  the  tumour  tlirec 
ounces  of  thick  flaky  pus  poured  out.  Part  of  tlie  wall 
was  removed,  and  the  patient  made  a  good  recovery. 

Probably  the  case  described  by  Liston  in  his  "  Elements 
of    Surgery"    (p.    IIO),   in  which    he    mentions  that  osteo- 


106  PERIOSTITIS. 

sarcoma  may  supervene  on  "  spina  ventosa"  of  the  lower 
jaw,  is  an  instance  in  point.  Tlie  case  was  that  of  a  young 
man,  aged  twenty-one,  who  had  an  abscess  of  the  lower  jaw  in 
the  molar  region,  which  was  evacuated  through  the  mouth, 
and  by  means  of  a  seton.  Two  years  after,  the  abscess  refilled, 
and  again  after  another  year ;  osteo-sarcoma  then  developed, 
necessitating  the  removal  of  half  the  jaw. 

A  remarkable  specimen  is  in  the  Museum  of  King's 
College,  of  a  large  abscess  of  the  lower  jaw,  for  which  half 
the  bone  was  removed  by  Sir  William  Eergusson.  The  speci- 
men has  been  divided  and  one  half  put  up  wet,  showing  the 
immensely  thickened  wall  of  the  cavity  ;  the  other  having 
been  macerated,  shows  merely  tlie  shell  of  expanded  and 
partially  absorbed  bone.  The  disease  had  followed  an  attack 
of  erysipelas  of  the  face  and  tooth-ache,  and  continued  to 
increase  for  eleven  years,  discharging  at  intervals  offensive 
matter. 

Fcrioslitis. — The  jaws,  no  less  than  other  bones  of  the 
skeleton,  are  subject  to  periostitis,  which  may  be  of  the 
acute  or  chronic  variety.  The  acute  forni  may  arise  from 
the  irritation  of  decayed  teeth,  or  in  young  subjects  from 
cutting  the  permanent  teeth  ;  from  mechanical  injury ;  or 
may  be  induced  by  a  specific  poison,  such  as  that  of  the 
exanthemata,  of  mercury  pushed  to  salivation,  or  the  vapour 
of  phosphorus.  In  strumous  children,  however,  periostitis 
may  occur  without  any  obvious  cause,  except  a  constitutional 
taint,  which  leads,  as  we  frequently  see,  to  periostitis  in 
other  parts  of  the  body. 

Mr.  Stanley,  in  his  work  on  "  Diseases  of  the  Bones" 
(p.  71),  alludes  to  cases  of  this  kind,  though  he  does  not 
appear  to  connect  them  with  a  strumous  diathesis.  He 
says,  ''  A  large  portion  of  the  lower  jaw  in  young  persons 
occasionally  perishes  without  any  previous  derangement  of 
health,  local  injury,  or  other  apparent  cause.  But  in  some 
cases  an  aching  in  the  bone  has  preceded  the  death  of  it. 
Such  examples  of  necrosis  usually  occur  in  early  life,  between 
the  fourth  and  twentieth  years,  but  rarely  later." 

The    symptoms  of  periostitis   are   pain,   which  is  aggra- 


PERIOSTITIS.  107 

vated  at  niglit ;  heat  of  the  part,  with  considorablc  swelling 
of  the  face  and  constitutional  disturbance ;  the  teeth  arc 
found  to  be  raised  somewhat  from  their  sockets  and 
loosened,  and  the  least  pressure  upon  them  gives  excru- 
ciating pain. 

In  all  these  cases  the  tendency  of  the  inflammation  to 
run  on  to  suppuration,  and  thus  induce  necrosis  of  the  bone, 
is  so  great  that  the  disease  is  often  not  recognized  in  its 
early  stage,  but  should  it  be  so,  the  treatment  relied  upon 
in  other  parts  of  the  body  would  be  applicable  here — viz., 
local  depletion  by  leeches,  a  free  incision  through  the 
affected  periosteum  to  give  exit  to  effusion,  followed  by 
poppy  fomentations,  and  the  exhibition  of  salines  and 
sedatives. 

The  more  chronic  form  of  periostitis  is  usually  of  syphi- 
litic origin,  and  leads  to  the  formation  of  nodes  here  as  in 
other  parts.  The  palate  is  especially  liable  to  these  swell- 
ings, which  are  due  to  effusion  between  the  periosteum  and 
the  bone,  and  which,  if  left  untreated,  will  as  surely  lead  to 
necrosis  as  the  more  acute  forms.  Mercury  is  inadmissible 
in  these  cases,  but  iodide  of  potassium  in  full  doses  will 
rapidly  remove  the  swelling,  and  restore  the  periosteum  to  a 
healthy  state. 

The  simple  form  of  periostitis,  which  will  lead  to  abscess 
and  perhaps  necrosis,  is  sometimes  very  insidious  in  its 
approach,  and  the  intermittent  pain,  recurring  usually  at 
night,  may  mislead  as  to  the  original  cause  of  the  attack, 
the  examination  of  the  teeth  being  neglected,  and  the 
attention  concentrated  on  a  supposed  constitutional  diathesis. 
It  is  well,  therefore,  in  all  cases  of  supposed  periosteal 
inflammation,  to  examine  the  condition  of  the  teeth,  both 
with  the  eye  and  by  striking  them  pretty  forcibly,  and  any 
tender  tooth  should  be  removed  ;  since,  according  to  Tomes, 
a  greater  or  lesser  degree  of  exostosis  of  the  tooth  itself  is 
pretty  certain  to  have  taken  place,  which  will  keep  up  the 
irritation. 

Dr.  Gross,  of  Philadelphia,  has  called  attention  to  a  form 
of  neuralgia  occurring   in  edentulous   jaws,  and   dependent 


108  PERIOSTITIS. 

upon  tliickeniiig  and  induration  of  the  alveolar  margin,  by 
vvhicli  the  remains  of  the  dental  nerves  become  compressed 
and  irritated.  He  recommends  removal  of  the  margin  of 
the  alveolus  with  cutting  forceps,  and  speaks  highly  of  the 
practice.  Having  seen  the  proceeding  adopted  on  several 
occasions  Ly  Mr.  Erichsen,  and  having  used  it  myself,  I 
think  that  there  are  undoubtedly  cases  of  neuralgia  which 
are  relieved  l)y  the  treatment,  but  that  it  is  by  no  means 
of  universal  application  in  cases  of  neuralgia  of  the  fifth 
nerve. 

Caries  of  the  jaws  of  idiopathic  origin  may  be  said  to  be 
unknown,  for,  as  pointed  out  by  Fergusson,  the  term  caries 
ought  not  to  be  aj)plied  to  the  ulcerations  met  with  in  con- 
nection with  the  formation  of  abscesses  or  the  separation  of 
sequestra.  In  cases  of  ulceration  and  extensive  destruction 
of  the  tissues  of  the  face  by  syphilis  or  lupus,  the  jawbones 
are  sometimes  involved  and  become  carious,  producing 
the  most  frightful  deformity ;  or  in  the  case  of  syphilis 
(probably  mercurio-syphilis  in  former  years),  the  disease 
may  begin  in  the  palate  and  gradually  destroy  it,  laying 
the  mouth  and  nose  into  one,  and  passing  forward  to  the 
face. 

In  the  Anliic  fur  Patlwlogisdic  Anatomic,  xviii.  347, 
Dr.  H.  Senftleben  has  given  an  elaborate  description  of  what 
he  terms  acute  rheumatic  periostitis  of  the  lower  jaw,  which 
appears,  however,  to  differ  in  no  essential  particular  from 
the  ordinary  form  of  acute  periostitis  following  exposure, 
&c.  He  says  that  it  attacks  perfectly  healthy  and  robust 
individuals  with  good  teeth,  after  severe  cold,  commencing 
with  violent  toothache  along  one  side  of  the  lower  jaw,  con- 
siderable and  often  very  intense  fever,  swelling  of  the  cheek 
and  gums,  difficulty  in  chewing,  &c.  Active  depletion  is 
recommended,  and  an  early  incision  if  matter  forms^  but 
necrosis  is  a  Aery  frequent  consequence.  {Si/denham 
Society  s  Year  Bool;  1863,  p.  259.) 

Magitot,  in  a  paper  read  before  the  xVcademy  of  ^Icdicine 
of  Talis  (1882)  has  described  a  form  of  alveolar  periostitis, 
whicli    In;    considers   [)uthogii()m()nic   of    diabetes.      Without 


DIABETIC    PEIMOSTITrS.  109 

going  so  far  as  this  Dr.  Pavyc  reognizes  the  affection  in  tlie 
following  extract  from  his  work  on  Diabetes  : — 

"  The  teeth  are  not  unfrequently  observed  to  become 
loosened  in  diabetes,  and  it  may  be  even  to  sucli  an  extent 
as  easily  to  drop  out.  There  is  evidently  some  direct  con- 
nection between  this  phenomenon  and  the  disease.  It  seems 
as  if  the  morbid  condition  of  the  system  prevailing  interfered 
with  the  nutritive  action  going  on  in  the  fang  and  its  socket, 
•and  so  led  to  the  result.  It  is  only  when  the  symptoms  are 
allowed  to  run  on  in  a  severe  form  that  it  is  noticed,  and 
supposing  the  teeth  to  have  become  already  loosened,  I  have 
known  them  again  become  firm  upon  the  disease  l)eing  con- 
trolled by  treatment." 


110 


CHAPTER  YIII. 

NECROSIS    OF    THE    JAWS. 

The  jaws  are  specially  liable  to  necrosis  consequent  upon 
inflammation,  but  there  is  a  difference  in  the  frequency  with 
which  the  upper  and  lower  jaw  is  attacked.  According  to 
Stanley  ("  Diseases  of  the  Bones,"  p.  69),  the  order  of  fre- 
quency of  necrosis  of  the  bones  of  the  skeleton  is  as  follows  : — 
Tibia,  femur,  humerus,  flat  cranial  bones,  loioer  jaw,  last  pha- 
lanx of  finger,  clavicle,  ulna,  radius,  fibula,  scapula,  ui:)^^ 
jaw,  pelvic  bones,  sternum,  ribs  ;  and  the  greater  immunity 
enjoyed  by  the  upper  as  compared  with  the  lower  jaw  is  due, 
no  doubt,  partly  to  its  less  exposed  position,  but  more  espe- 
cially to  the  fact  that  necrosis  occurs  less  frequently  in  can- 
cellous than  in  compact  bone.  The  great  difl'erence  in  the 
supply  of  blood  to  the  two  bones  must  also  have  an  influence, 
the  upper  jaw  being  supplied  by  very  numerous  branches  of 
the  internal  maxillary  arteries,  which  inosculate  freely  from 
side  to  side,  whilst  the  lower  jaw  is  supplied  by  two  small 
branches  only,  which  do  not  anastomose. 

The  causes  and  early  symptoms  of  necrosis  are  usually 
those  of  periostitis,  and  have  been  described  under  that 
heading.  When  the  inflammation  fails  to  be  arrested,  the 
plastic  effusion  between  the  periosteum  and  the  bone  be- 
comes rapidly  converted  into  pus,  and  this,  by  separating  the 
membrane  from  the  bone,  soon  leads  to  the  death  of  the 
latter.  In  long  bones,  where  there  is  a  medullary  canal 
abundantly  supplied  with  blood,  or  in  the  upper  jaw  where 
the  vascularity  is  great,  the  bone  is  able  to  resist  this  ne- 
crotic action  for  some  time,  and  even  to  recover,  although 
bared    of  iieriosteuni    fur    a    wliilc;   but    in   tlie   lower  jnw 


SYMPTOMS    OF    NECROSIS. 


Ill 


this  cannot  be  expected,  and  it  is  found  that  a  very  few 
hours  after  suppuration  has  been  excited,  the  bone  is  in  great 
part  necrosed.  This  action  does  not  extend,  however,  of 
necessity  to  the  whole  thickness  of  tlie  jaw,  for  the  disease 
almost  invariably  attacks  the  outer  side  of  the  bone  first,  and 
if  timely  relief  be  afforded  to  the  pent-up  matter,  the  peri- 
osteum on  the  inner  side  will  escape  injury,  and  that  portion 
of  the  bone  will  be  preserved.  Or,  even  if  the  disease  affect 
the  whole  thickness  of  the  bone,  it  may  still  be  confined  to 
the  alveolar  border,  which  may  exfoliate  leaving  the  base  of 

Fig.  46. 


the  jaw  intact.  Of  this  an  excellent  example  is  preserved 
in  the  Museum  of  the  College  of  Surgeons  in  Dublin,  where 
an  unbroken  exfoliation  of  the  entire  alveolar  arch  of  the 
lower  jaw,  with  the  teeth  still  in  it,  closely  resembles  a  set 
of  artificial  teeth.  In  the  upper  jaw  also  the  disease  may 
attack  one  part  of  the  bone,  the  rest  being  intact,  and  thus  a 
sequestrum  may  be  formed  from  either  the  alveolus  or  the 


112  NECROSIS    OF   THE   JAWS. 

palatine  plate,  or  occasionally  from  botli,  of  whicli  a  good 
example  is  seen  in  the  preceding  woodcuts,  for  wliicli  I 
am  indel)ted  to  Mr.  Nicholson,  of  Liverpool,  fig.  46  sho\ving 
the  alveolar  border,  and  fig.  47  the  palatine  plate  of  the 
sequestrum.  When  the  pus  resulting  from  the  inflammation 
is  unrelieved  by  timely  incision,  it  tends  to  gravitate  and 
find  an  exit  for  itself  at  the  most  easily  reached  surface. 
Thus,  in  the  case  of  the  upper  jaw  the  tendency  of  the 
matter  is  to  burst  into  the  mouth,  and  it  is  the  exception  to 
find  openings  on  the  face,  except  when  the  whole  of  the 
bone  is  involved.  In  the  case  of  the  lower  jaw,  on  the 
contrary,  the  matter  finds  numerous  openings  for  itself  along 
the  lower  margin  of  the  bone,  on  its  outer  aspect,  and  even 
at  some  distance  down  the  neck. 

The  effect  of  necrosis  of  the  ja^^-  u]»on  tlie  teetli  is  easily 
seen,  since  in  cases  of  entire  necrosis  they  become  loose  and 
discoloured,  and  even  in  ]-)artial  necrosis  they  cannot  bear 
the  least  pressure,  owing  to  tlie  ]"»ain  produced.  In  the 
majority  of  cases  of  necrosis  the  loose  teeth  prove  such  an 
annoyance  to  the  patient  tliat  they  are  extracted,  if  they  do 
not  drop  out  of  their  own  accord  ;  but  cases  liave  been  met 
with,  and  will  be  subsecpiently  referred  to,  in  which  the 
teeth  remained  m  sifu  long  after  the  bone  was  both  necrosed 
and  had  been  removed.  In  the  case  of  young  subjects,  ex- 
tensive necrosis  of  the  jaw  will  ordinarily  destroy  the  germs 
of  the  permanent  teeth  as  well  as  the  temporary  teeth  already 
cut,  and  of  this  a  good  example  is  to  be  seen  in  the  Museum 
of  St.  Mary's  Hospital,  in  a  sequestrum  of  the  lower  jaw  from 
a  girl  of  from  three  to  four,  after  small-]50x.  The  necrosis 
involves  the  whole  of  tlie  right  side  of  the  body  of  the  bone 
and  a  portion  of  the  ramus,  including  fixc  temporary  teeth 
and  the  half-developed  ]Dcrmanent  teeth,  and,  reaching  beyond 
the  symphysis,  includes  a  portion  of  the  outer  plate  of  the 
left  incisive  region.  lUit  it  has  occasionally  happened,  after 
repair  of  the  bone  in  young  subjects,  that  the  ]-»ermanent 
teeth  have  been  cut,  thus  leading  to  the  supposition  of  a  re- 
production of  the  teeth  as  well  as  of  the  bone.  Mv.  Tomes 
has  pointed  out,  that  in  these  cases  the  sequestrum  did   not 


NECROSIS   OF   THE   JAWS.  113 

involve  the  pulps  of  the  permanent  teeth,  although  encroach- 
ing upon  them,  and  they  therefore  remained  in  situ,  whilst 
the  new  bone  was  formed  around  them,  and  the  teeth,  when 
fully  developed,  made  their  appearance  in  the  ordinary 
way. 

From  a  consideration  of  these  cases  Mr.  Tomes  draws  the 
following  valuable  practical  deductions  as  regards  the  treat- 
ment of  necrosis  of  the  young  jaw,  which  may  be  usefully 
referred  to  at  this  point : — "  I  think  all  will  agree  that  it  is 
desirable  in  those  cases  where  necrosis  of  tlie  jaw  occurs 
during  the  presence  of  the  temporary  teeth,  that  the  seques- 
trum should  be  allowed  to  remain  until  it  is  perfectly  de- 
tached both  from  the  contiguous  bone  and  soft  parts,  before 
its  withdrawal  is  attempted ;  and  that  its  removal  should  be 
effected  with  the  least  possible  injury  to  the  latter,  so  that 
the  permanent  teeth,  if  not  destroyed  by  the  disease,  may 
be  placed  under  the  most  favourable  circumstances  for  their 
future  growth  and  evolution."     ("  Dental  Surgery,"  p.  75.) 

In  1868  Mr.  Oliver  Chalk  brought  before  the  Odonto- 
logical  Society  some  cases  which,  in  his  opinion,  proved 
that  a  fresh  development  of  teeth  might  occur  even  after 
the  jaw,  together  with  the  germs  of  the  second  set,  had  been 
removed  by  necrosis.  Having  had  the  opportunity,  how- 
ever, of  hearing  the  paper  in  question,  and  of  examining  Mr. 
Chalk's  preparations,  I  must  remain  of  my  previous  opinion, 
which  coincides  with  that  of  Mr.  Tomes — that  such  an  event 
is  impossible,  and  that  the  germs  of  any  subsequently  cut 
teeth  must  have  been  preserved,  and  become  enclosed  in  the 
reparative  material  of  the  jaw.  (See  British  Journal  of  Dental 
Science,  Feb.  1868.) 

A  specimen  of  necrosis,  which  accompanied  this  essay 
(College  of  Surgeons  Museum,  1440)  was  from  a  boy 
named  Barton  Blackman,  who  subsequently  came  under  my 
care  with  closure  of  the  jaws  by  cicatrices,  and  was  removed 
by  the  late  Mr.  Martin,  of  Portsmouth,  in  1856,  when  the 
boy  was  ten  years  old.  He  had  extensive  necrosis  of  both 
jaws  after  fever,  and  the  portions  of  sequestra  preserved  show 
exceedingly  well  the  relation  of  the  permanent  to  the  tem- 

I 


114 


NECROSIS   OF  THE   JAWS. 


porary  teeth ;  in    some  instances    tlie    partly-formed  second 
tooth  having  come  away,  and  in  otliers  being  left  behind. 

Ecmntliemafous  Necrosis. — Under  this  name^  Mr.  Salter 
has  described  (Giii/s  Hospital  liqwrts,  vol.  iv.,  and  System 
of  Sargenj,  vol.  ii.)  the  form  of  necrosis  of  the  jaw  in  chil- 
dren which  depends  upon  the  poisonous  effects  of  some  of 
the  exanthematoiis  diseases,  and  especially  scarlet  fever. 
Mr.  Salter  claims  to  have  been  the  first  to  call  attention  to 
this  form  of  necrosis,  and  to  trace  it  to  its  cause,  and  has 
met  M'ith  over  twenty  instances  of  the  affection.  In  the  Pa- 
tlwlocjical  Societi/'s  Transactions  (vol.  xi.),  he  has  described 
and  figured  seven  specimens  of  the  exfoliation — four  after 
scarlet  fever,  two  after  measles,  and  one  after  small-pox. 
The  disease  appears  to   occur  most  frequently  about  the  age 

Fig.  48. 


A,  anterior;  e,  external;  c,  internal  view  of  inter-maxillary  bones. 

of  five  or  six  years,  when  each  jaw  contains  the  whole  of  the 
first  set,  and  the  germs,  more  or  less  advanced,  of  the  second 
set  of  teeth ;  but  Mr.  Bryant  has  recorded  [ruthological 
Sac.  Trans.,  vol.  x.)  a  case  of  exfoliation  of  the  intermaxil- 
lary bones  after  measles,  in  a  child  of  three  (fig.  48),  and 
the  boy  Barton  Blackman,  already  referred  to,  is  an  instance 
of  the  kind,  at  the  age  of  ten. 

The  disease  first  shows  itself  a  few  weeks  after  the  occur- 
rence of  the  feverish  attack,  in  tenderness  of  the  mouth  and 
foetor  of   the  Ijreath,  and  the  gum  is  seen  to  be  separated 


EXANTHEMATOUS    NECROSIS.  115 

from  the  teeth  and  alveohis.  The  disease  is  remarkably 
symmetrical,  appearing  almost  simultaneously  on  both  sides 
of  the  jaw,  and  rapidly  denuding  the  bone,  thus  leading  to 
necrosis  and  subsequent  exfoliation  of  considerable  portions 
of  it.  These  usually  include  the  whole  depth  of  the  alveolus, 
together  with  the  partially-developed  permanent  teeth  ;  but 
no  case  has  been  met  with  in  which  the  lower  border  of  the 
jaw  was  involved. 

It  is  possible  tliat  this  disorder  might  be  confounded  with 
cancriim  oris  in  its  early  stage,  but  the  aljsence  of  ulceration 
of  the  gum  would  at  once  distinguish  it. 

I  am  indebted  to  Mr.  N.  Tracy,  of  Ipswich,  for  a  prepara- 
tion of  necrosis  follo\\^ing  scarlet  fever^  in  a  girl  of  thirteen, 
which  accompanied  this  essay  (College  of  Surgeons  Museum, 
1441).  The  disease  was,  as  usual,  symmetrical,  but  the 
right  side  was  more  deeply  involved  than  the  left.  On  the 
right  side  the  sequestrum,  1|  inch  in  length,  and  |  inch  in 
depth,  contained  the  permanent  first  molar  and  the  uncut 
permanent  bicuspid  teeth,  besides  a  temporary  molar ;  and 
involved  part  of  the  socket  of  the  second  permanent  molar 
behind,  and  of  the  canine  in  front.  On  the  left  side  the 
disease  involved  only  a  portion  of  the  alveolar  border,  in- 
cluding a  temporary  molar  tooth.  A  model,  taken  three 
years  later,  showed  the  permanent  gap  left  between  the 
canine  and  the  first  molar  teeth  on  the  right  side. 

A  very  remarkably  extensive  necrosis  of  the  lower  jaw, 
occurring  in  a  child  of  four,  is  shown  in  fig.  49,  taken,  by 
permission,  from  a  specimen  brought  before  the  Pathological 
Society  by  Mr.  Waren  Tay  {Fatliological  Soc.  Trans.,  1874). 
The  sequestrum  includes  the  whole  lower  jaw,  with  the  ex- 
ception of  one  condyle,  and  the  subsequent  repair  seems  to 
have  been  very  complete.  The  cause  of  the  mischief  appears 
to  have  been  doubtful,  but  may  have  been  due  to  the  trick 
of  sucking  lucifer-matches,  in  which  the  cliild  is  said  to  have 
indulged.  Mr.  Tay  brought  this  patient  again  before  the 
Pathological  Society  in  November,  1883,  when  there  was  a 
firm  ring  of  new  bone  present  in  the  situation  of  the  jaw, 
quite  firm  enough  to  give  support  to  artificial  teeth  if  they 

I  2 


116 


NECROSIS    OF   THE    JAWS. 


were  supplied.  At  the  j^osterior  part  of  the  left  side  a  sharp- 
edged  tootli  has  made  its  appearance  lately.  He  could  depress 
and  elevate  the  jaw  vigorously.  On  the  left  side,  where  the 
condyle  was  wholly  removed,  there  was  good  lateral  move- 
ment, hut  on  the  right  side  the  movements  were  not  so  free, 
tliough  he  had  no  difhculty  in  chewing  food. 

Mr.  Salter  regards  necrosis  after  continued  fever  as  of 
rare  occurrence.  In  the  Guy's  Hospital  Museum,  however, 
is  a  portion  of  lower  jaw  (1091,  vii.),  consisting  of  condyle, 
angle,  and  part  of  the    body    of   the    Lone,    separated  hy 

Fig.  49. 


necrosis  after  fever,  from  a  boy  of  fourteen.  He  recovered 
with  comparatively  trifling  deformity,  and  the  skin  remained 
sensitive,  although  a  large  part  of  the  trunk  of  the  nerve 
must  have  been  destroyed.  In  St.  George's  HosiDital 
Museum  also  there  are  specimens  (II.  91  and  95)  of  necrosis 
of  the  lower  jaw  and  clavicle  in  fever.  A  case  of  very  ex- 
tensive necrosis  occurring  after  fever,  under  Mr.  Stanley's 
care,  will  be  referred  to  further  on. 

The  repair  of  extensive  necrosis   of  the  alveolus  of  this 
character,  in  young  persons,  is   a  subject  of  some  interest. 


REPAIR    AFTER    NECROSIS.  117 

In  the  lower  jaw  no  repair  of  the  gap  is  necessary,  since, 
fortunately,  the  disease  leaves  the  strong  lower  border  of  tlie 
bone  untouched,  which  preserves  the  contour  of  the  face,  and 
forms  a  base  for  artificial  teeth  at  a  later  date.  In  the 
case  of  the  upper  jaw,  however,  a  development  of  tough 
fibrous  tissue  takes  place,  which  gradually  fills  up  pretty 
completely  the  cavity  left,  and  thus,  to  a  great  degree,  pre- 
vents the  falling  in  of  the  cheek  and  consequent  deformity 
which  would  otherwise  occur.  In  the  Museum  of  King's 
College  is  a  preparation  of  the  nearly  entire  upper  jaw  of  a 
child,  which  became  necrosed  as  a  consequence  of  small-pox, 
and  was  removed  by  Mr.  Partridge,  when  surgeon  to  the 
Charing  Cross  Hospital.  By  the  kindness  of  Mr.  Canton, 
I  have  had  access  to  a  photograph  of  this  patient,  taken 
within  the  last  few  years,  which  shows  the  very  slight  de- 
formity now  present,  in  consequence  of  this  repair  of  the 
original  mischief. 

This  statement  respecting  the  repair  of  a  necrosed  superior 
maxilla  is,  at  first  sight,  in  opposition  to  the  opinion  of 
Stanley  ("On  Diseases  of  the  Bones,"  p.  72),  who  says, 
"  under  whatever  circumstances  the  necrosis  has  occurred,  it 
is  not,  as  I  believe,  ever  followed  by  the  slightest  reproduc- 
tion of  the  lost  bone."  This  I  believe  to  be  true  quoad 
the  reproduction  of  actual  bone,  and  in  the  case  of  adults, 
but  the  filling  up  of  the  cavity  by  fibrous  tissue  I  have  wit- 
nessed in  young  subjects  after  the  removal  of  tumours. 

The  case  upon  which  Mr.  Stanley  founds  the  above  ob- 
servation is  a  remarkable  one,  from  the  apparent  want  of 
cause  for  the  extensive  mischief  that  ensued.  The  patient 
was  a  man  aged  thirty,  who,  twelve  months  before  he  applied 
to  Mr.  Stanley,  began  to  suffer  pain  in  his  upper  jaw,  soon 
after  which  the  teeth  fell  out  of  their  sockets,  and  matter 
was  discharged  into  the  mouth.  When  the  dead  bone  was 
sufficiently  loosened,  Mr.  Stanley  drew  away  the  greater 
part  of  both  superior  maxillae. 

A  very  similar  case  occurring  in  a  strumous  man,  aged 
forty,  is  recorded  by  Mr.  Ernest  Hart,  in  the  Lancet,  19th 
July,  1863,  and,  by  the  kindness  of  that   gentleman,  I  am 


118 


NECROSIS   OF    THE    JAWS. 


enabled  to  reproduce  the  drawings   of  the    bones   when  re- 
moved^ and  of  the  patient  after  the  operation. 


Fk;.  50. 


Fu;.  51. 


A  second  case,  very  similar  to  the  above  as  respects  the 
absence  of  cause  for  the  disease,  has  been  recently  under  my 
notice,  the  report  of  it  having  been  kindly  furnished  to  nie 
by  Dr.  Garnham,  of  the  Peninsular  and  Oriental  Company's 
.Service.  The  patient,  aged  forty,  was  an  engineer  in  the 
Company's  service,  and  enjoyed  perfectly  good  health  in  the 
tropics  for  some  years,  but  soon  after  his  return  to  England 
his  mouth  became  sore,  sloughing  of  the  gums  took  place, 
and,  when  I  hrst  saw  him,  very  large  portions  of  the 
alveolus  of  tlie  loM^er  jaw  were  necrosed,  and  lying  exposed 
in  the  mouth.  Subsequently  these  came  away  or  were 
removed  by  Dr.  Garnham,  and  the  patient  having  been 
reduced  to  an  edentulous  condition,  as  regards  the  lower 
jaw,  it  became  necessary  to  apply  to  Mr.  C.  J.  Fox,  the 
dentist,  for  artificial  aid.  Dr.  Garnham  attributes  the  disease 
to  depression  of  the  vital  powers,  owing  to  long  residence  in 
warm  climates. 

Any  ulcerative  affection  of  the  mouth  may  lead  to 
necrosis  of  the  jaw  :  thus  it  lias  been  met  with  during 
scurvy,  after  cancrum  oris,  and  after  mercurial  salivation. 
A  very  extensive  sequestrum  resulting  from  cancrum  oris 
is  preserved  in  Guy's  Museum  {1091,  v.),  consisting  of  the 
symphysis  and  horizontal  rami  of  tlie  lower  jaw,  together 
with  the   first  two  molar  teeth.     Four  years  after  its  re- 


NECROSIS    FHOM    MERCURY.  119 

iiioval,  an  osseous  growth  was  found  to  have  taken  the  place 
of  the  original  portion  of  the  lower  jaw,  the  power  of  mas- 
tication being  good  and  the  sense  of  feeling  nearly  perfect. 
Profuse  salivation  from  mercury  being  now  of  rare  occur- 
rence, necrosis  from  this  cause  is  but  seldom  met  with;  but 
in  former  years  the  remedy  seems  sometimes  to  have  been 
worse  than  the  disease  :  thus  Mr.  Key  presented  to  Guy's 
IMuseum  a  sequestrum  consisting  of  two-thirds  of  the 
alveolar  processes  of  the  lower  jaw,  the  disease  having  been 
induced  by  the  use  of  mercury  for  ovarian  dropsy.  The  ex- 
foliation of  the  entire  alveolus  in  the  Museum  of  the  Dublin 
College  of  Surgeons,  already  described,  was  also  due  to  the 
exhibition  of  mercury.  In  the  American  Medical  Times  of 
February  23,  1861,  Dr.  E.  S.  Cooper  records  the  case  of  a 
cliild,  aged  seven,  in  whom  necrosis  involving  the  left  half 
of  tlie  lower  jaw,  including  the  coronoid  and  condyloid  pro- 
cesses, had  been  produced  by  the  administration  of  calomel. 
After  removal  of  the  sequestrum  reproduction  of  the  jaw 
took  place,  the  reproduced  bone  being  at  first  very  much 
larger  than  the  natural  bone,  but  gradually  improving  in 
shape. 

Mr.  Stanley  mentions  (p.  72),  and  gives  a  drawing  of  a 
sequestrum  preserved  in  St.  Bartholomew's  Museum  (I.  102), 
embracing  nearly  the  whole  body  of  the  lower  jaw,  which 
suffered  necrosis  after  the  administration  of  a  few  grains  of 
calomel  in  a  case  of  fever.  It  might  be  doubted  whether  the 
necrosis  was  not  due  as  much  to  tlie  fever  as  to  the  calomel 
in  this  case,  but  that  Mr.  Stanley  mentions  that  the  patient 
had  excessive  salivation  and  severe  inflammation  in  the  gums 
and  cheeks. 

The  severe  form  of  mercurial  necrosis^  of  which 
patients  suffering  from  syphilis  were  mostly  the  victims  in 
the  days  when  salivation  was  looked  upon  as  a  necessary 
part  of  the  treatment,  is  now  practically  unknown.  It  was 
formerly  met  with  also  as  a  result  of  the  destructive  ptyalism, 
produced  by  tlie  fumes  of  liquid  mercury  employed  in  the 
manufacture  of  looking-glasses.  When  glass  plates  were 
converted  into   mirrors  by  sliding   and   compressing   them 


120  NECROSIS    OF    THE   JAWS. 

on  to  sheets  of  tin-foil  covered  with  pure  quicksilver, 
the  men  employed  were  liable  to  have  their  teeth  drop 
out,  and  frequently  lost  portions  of  the  jaws,  their  lives 
being  notoriously  shortened.  Since  the  introduction  of  a 
chemical  process  by  which  the  mercury  is  deposited  on  the 
glass,  these  cases  of  induced  necrosis  have  become  almost 
unknown. 

Syphilitic  'poison  frequently  produces  necrosis  of  the  jaws  ; 
and  here  we  find  the  observation  of  Stanley  hold  good  as  in 
other  parts  of  the  body.  He  says  (p.  7^)  "  Syphilis  pro- 
duces its  effects  mostly  upon  the  compact  osseous  textures, 
and  in  portions  of  bones  which  have  thin  soft  coverings,  as 
the  flat  cranial  bones ;"  and  it  is  in  the  compact  tissue  of 
the  palatine  plate  of  the  superior  maxilla,  which  is  thinly 
covered  by  mucous  membrane,  that  we  find  the  ravages  of 
syphilis  most  frequent.  Occasionally  the  disease  leads  to 
necrosis  of  portions  of  the  compact  tissue  of  tlie  lower  jaw, 
or  attacks  the  alveolus,  or  body  of  the  upper  jaw.  Of  this  I 
have  lately  had  two  examples  under  my  own  care,  one  in  a 
medical  man,  from  whom  I  extracted  a  large  piece  of  necrosed 
alveolus,  and  the  other  in  a  discharged  soldier,  aged  twenty- 
three,  in  whom  also  there  was  extensive  necrosis  of  the 
alveolus,  extending  from  the  lateral  incisor  to  the  first 
molar  on  the  right  side.  There  was  no  question  as  to  the 
cause  of  the  disease  in  either  case.  In  cases  of  extensive 
tertiary  ulceration  of  the  face  also,  the  bones  may  become 
secondarily  affected. 

The  question  of  the  influence  of  syphilis  in  producing 
necrosis  of  the  alveolus,  derives  additional  interest  from 
the  recent  trial  of  an  action  against  a  dentist  for  damage 
due  to  necrosis,  said  to  have  been  caused  by  the  unskilful 
extraction  of  a  tooth  some  months  before.  In  tliis  case  one 
surgeon  swore  that  necrosis  of  the  jaw  from  syphilis  was 
unknown,  whilst  the  opposite  view  was  strongly  maintained 
by  surgeons  of  great  experience  in  syphilitic  diseases  {Britiah 
Medical  Journal,  August,  1871). 

The  proper  local  treatment  of  any  ulceration  or  necrosis 
of  the   palate  is  to  protect  the  part  from  contact  of  the 


THE    USE    OF    OBTURATORS.  121 

tongue  and  food,  and  to  close  the  aperture  by  a  properly  fitting 
plate  of  metal  or  vulcanite,  attached  to  the  teeth  and  arching 
immediately  below  the  jmlate,  without  making  pressure  upon 
the  edges  of  the  hole  itself.  A  caution  may  be  given  against 
any  attempt  on  the  part  of  the  surgeon  or  patient  to  fill 
the  gap  in  the  roof  of  the  mouth  by  any  form  of  plug  fitting 
into  the  hole  left,  the  effect  of  which  is  to  enlarge  the  aper- 
ture by  absorjDtion,  so  that  the  size  of  the  plug  has  to  be 
constantly  increased  in  order  to  make  it  effectual.  A  pre- 
paration in  St.  Bartholomew's  Museum  shows  the  extent  to 
which  this  absorption  may  be  carried  in  process  of  years. 
The  following  is  the  description  given  in  the  Museum 
Catalogue : — 

"  The  base  of  a  skull  from  an  elderly  woman,  who  ap- 
peared to  have  been  long  in  the  habit  of  wearing  a  plug  to 
close  an  opening  in  the  palate.  The  opening  gradually 
enlarging,  attained  such  a  size  that  nothing  remains  of  the 
palatine  portions  of  the  superior  maxillary  and  palate  bones, 
and  the  alveolar  border  of  the  jaw  is  reduced  to  a  very  thin 
plate,  without  any  trace  of  the  sockets  of  the  teeth.  The 
antrum  is  on  both  sides  obliterated  by  the  apposition  of  its 
walls,  its  inner  wall  having  probably  been  pushed  outwards 
as  the  plug  was  enlarged  to  fit  the  enlarging  aperture  in 
the  palate.  Nearly  the  whole  of  the  vomer  also  has  been 
destroyed,  and  the  superior  ethmoidal  cells  are  laid  open. 
The  plug  is  preserved  ;  it  is  composed  of  a  large  circular 
cork,  with  tape  wound  round  it,  and  measures  an  inch  and 
three-quarters  in  diameter,  and  an  inch  in  depth.  The  his- 
tory of  the  patient  is  unknown.  She  was  brought  from  a 
workhouse  to  the  dissecting  rooms,  with  the  plug  tightly  and 
smoothly  fitted  in  the  roof  of  the  mouth." — St,  Bartholomew's 
Catalogue,  14. 

Even  the  employment  of  a  piece  of  softened  gutta-perclia 
is  not  unattended  with  risk  :  thus,  several  years  ago  I  saw, 
with  Mr.  Lawson,  a  case  in  which  the  patient  had  thrust  a 
considerable  quantity  of  softened  gutta-percha  through  an 
aperture  in  the  palate  into  the  nostril,  where  it  formed  a 
hard    mass,  which    was    extracted  only  with    the   greatest 


122  NECROSIS    OF   THE    JAWS. 

difficulty  and  at  the  expense  of  tearing  one  of  the 
alai. 

Plios]iliorus-Nccrosis. — This,  which  is  perhaps  the  most 
formidable  kind  of  necrosis  of  the  jaw,  is  a  disease  of  modern 
time,  having  been  called  into  existence  only  since  the  intro- 
duction of  lucifer-matches,  into  the  inflammable  material  of 
which  i^hosphorus  largely  enters.  The  earlic^st  mention  by 
British  writers  of  disease  in  connexion  with  the  manufacture 
of  lucifers,  appears  to  have  been  by  Dr.  Wilks,  in  the  Giujs 
Hospital  Reports  of  1846-47  ;  but  a  paragraph  from  a 
German  author  upon  the  subject  is  quoted  in  the  Lancet  of 
August  29,  1846.  The  notice  in  the  Guys  Hosiyital  Firports 
is  of  a  case  of  disease  of  tlie  lower  jaw  with  exfoliation, 
occurring  in  a  lucifer-match  maker ;  and  the  remark  is 
made  that  the  disease  had  been  noticed  to  be  common 
among  workers  in  lucifer  manufactories — =a  branch  of  in- 
dustry which  had  then  been  introduced  into  London  some 
ten  years.  In  Germany,  however  (where  lucifer  manufac- 
tories were  started  some  years  earlier  than  in  England), 
phosphorus-necrosis  was  recognised  as  early  as  1839  by 
Lorinser,  who  published  a  paper  upon  the  subject  in  1845, 
and  was  followed  by  8trohl,  Heyfclder,  lloussel,  and  Gen- 
drin,  and  by  Sedillot,  in  1846.  In  1847  Drs.  Von  Bibra  and 
Geist,  of  Erlangen,  published  a  work  (Die  Krankheiten 
der  Arbeiter  in  den  I*hosphorziindholzfabriken,  insbesondere 
das  Leiden  der  Kieferknochen  durch  Phosphordampfe), 
whicli  forms  the  T)asis  of  our  present  knowledge  of  the  sub- 
ject, and  the  conclusions  of  which  further  experience  has 
fully  confirmed. 

In  London  the  lucifer  manufactories  being  ]3rincipally  at 
the  East-end,  cases  of  phosphorus-necrosis  are  most  common 
in  St.  Bartholomew's,  the  London,  and  the  Borough  hos- 
pitals ;  and  their  museums,  especially  tliat  of  St.  Bartho- 
lomew's, are  very  rich  in  specimens.  The  medical  officers 
of  these  institutions  having  thus  had  special  opportunities  of 
study,  have  not  failed  to  record  their  experience,  and  refe- 
rence may  be  made  to  valuable  clinical  lectures  upon  the 


PHOSPHORUS-NECROSIS.  123 

subject  by  Mr.  Simon  {Lancet,  1850),  Sir  J.  Paget  {Medical 
Times  and  Gazette,  1862),  and  Mr.  Adams  {Mediccd  Times 
and  Gazette,  1863)  ;  and  to  the  essay  on  Surgical  Dis- 
eases connected  witli  the  Teeth,  by  Mr.  J.  Salter  {Systan  of 
Surcjerij,  vol.  ii.). 

The  cause  of  the  disease  is,  unquestionably,  the  fumes  of 
the  phosphorus  which  are  inhaled  by  the  operatives  during 
the  process  of  "  dipping"  the  matches,  and  in  a  lesser  degree 
during  the  counting  and  packing  them.  When  the  disease 
first  showed  itself  in  Germany,  it  was  thought  that  it  de- 
pended upon  the  admixture  of  arsenic  with  the  phosphorus  ; 
and  it  is  curious  that  in  the  Museum  of  St,  Bartholomew's 
there  are  some  bones  of  cows  from  tlie  neighbourhood  of 
Swansea,  which,  under  the  influence  of  arsenical  vapour, 
have  become  enlarged  and  covered  with  a  new  bone  forma- 
tion closely  resembling  that  around  phosphorus-necrosis.  It 
has  been  proved,  however,  that  arsenic  has  nothing  to  do 
with  the  disease  ;  and  if  proof  positive  were  wanting  that 
phosphorus  alone  is  the  deleterious  agent,  it  is  supplied  by 
a  case  quoted  by  Sir  J.  Paget,  in  the  lecture  referred  to, 
of  a  man  who  induced  necrosis  of  his  jaws  by  inhaling 
fumes  of  phosphoric  acid  as  a  quack  remedy  for  "  nervous- 
ness." 

Lorinser  and  the  earlier  writers  considered  the  disease  to 
consist  in  blood-poisoning,  the  necrosis  of  the  jaw  being 
consequent  thereupon,  and  Mr.  Adams  {loc.  cit.)  thinks  that 
the  theory  of  blood-poisoning  should  not  be  altogether  dis- 
carded, since  the  local  disease  would  not  account  for  the 
constitutional  symptoms  experienced.  Tliis  view  has  recently 
received  the  support  of  the  eminent  Berlin  surgeon  Yon 
Langenbeck,  who  maintains  that  all  the  general  symptoms 
of  phosphorus-poisoning  are  present  long  before  the  local 
disease,  which  he  calls  periostitis  rather  than  necrosis, 
manifests  itself.  {Berliner  KliniscJic  JVocJicnschrift,  Jan.  8th, 
1872.)  The  majority  of  surgeons  agree,  however,  in  con- 
sidering the  aftection  essentially  a  local  one,  the  consti- 
tutional symptoms    being   only  consecutive,  and  an  interest- 


124  NECROSIS    OF   THE   JAWS. 

iug  account  of  the  post-mortem  examination  of  a  case  of 
general  poisoning  by  phosphorus,  following  necrosis  of  the 
jaw,  will  be  found  in  the  FatJwlof/ical  Society's  Transactions 
for  1869. 

It  is  found  that  the  phosphorus  fumes  produce  no  inju- 
rious effects  so  long  as  the  teeth  and  gums  of  the  workers 
are  sound,  but  as  soon  as  the  teeth  become  carious,  or  if  a 
tooth  is  extracted  so  as  to  leave  an  open  socket,  the  disease 
rapidly  develops  itself.  The  experiments  upon  animals,  by 
Geist  and  Von  Bibra,  are  amply  confirmatory  of  this  view, 
since  they  found  that  rabbits  exposed  to  phosphoric  fumes 
suffered  no  injury  so  long  as  the  teeth  and  jaws  were  unin- 
jured, but  that  if  the  teeth  were  extracted  or  the  jaw  broken 
periostitis  and  necrosis  raj)idly  resulted.  On  the  other 
hand,  it  may  be  mentioned  that  a  case  has  been  recorded  by 
Gisindiidiev  (Journal  fiir  Xinderkrcmkheitcn,  1861),  of  necrosis 
of  the  upper  jaw  from  phosphorus  fumes  in  a  child  but  six 
weeks  old,  and  in  whom  therefore  the  teeth  were  not  de- 
veloped, and  Langenbeck  is  opposed  to  the  notion  that 
carious  teeth  predispose  to  the  disorder. 

The  liability  of  the  two  jaws  to  the  disease  appears  to  be 
about  the  same,  or  perhaps  with  a  slight  preponderance  in 
favour  of  the  lower  jaw.  Of  52  cases  given  by  German 
authorities,  21  were  of  the  superior  maxilla,  25  of  the  in- 
ferior maxilla ;  in  5  both  jaws  were  involved,  and  one  case 
is  uncertain.  [British  and  Foreign  Medico- Chirurgical 
Review,  April,  1848.)  Mr.  Salter  {loc.  cit.)  says,  "  In  five 
cases  which  I  have  witnessed,  the  lower  jaw  was  diseased 
in  four,  and  the  upper  in  one ;  whereas  four  which  occurred 
in  the  practice  of  a  surgical  friend,  were  confined  to  the 
upper  jaw.  In  seventeen  instances  of  which  I  have  obtained 
particulars  or  seen  specimens^  nine  were  connected  with  the 
superior,  and  eight  with  the  inferior  maxilla.  The  disease 
is  therefore  pretty  evenly  balanced  between  the  two 
jaws."  The  St.  Bartholomew's  Hospital  Museum  contains 
excellent  specimens  of  both  jaws  affected  by  this  form  of 
disease. 

The  Symptoms  of  Necrosis   of   the  jaws,   from   whatever 


SYMPTOMS    OF    NECROSIS.  125 

cause,  are  much  the  same,  but  as  they  present  themselves 
in  the  most  marked  degree  in  phosphorus-necrosis,  it  will  be 
convenient  to  describe  them  under  this  head. 

Pain  referred  to  the  teeth  is  one  of  the  earliest  symp- 
toms of  the  disease,  and  this,  which  was  intermittent  at  first, 
becomes  at  length  continuous.  The  teeth  become  loose, 
and  pus  is  seen  to  exude  from  their  sockets.  At  the  same 
time  the  gums  become  swollen  and  tender,  and  are  detached 
to  a  greater  or  lesser  degree  from  the  alveoli,  giving  constant 
exit  to  a  purulent  discharge.  In  all  cases  of  necrosis  the 
face  is  swollen,  so  that,  if  only  one  side  of  the  jaw  is  affected, 
a  peculiar  lop-sided  effect  is  produced.  In  the  cases  of 
phosphorus-necrosis,  however,  the  swelling  of  the  face  is 
much  more  marked,  the  soft  tissues  around  the  bone  being 
infiltrated  and  puffy  to  an  extent  which  is  not  witnessed  in 
other  forms  of  the  disease.  One  or  more  openings  now  form 
externally,  through  which  pus  constantly  exudes,  and  the 
probe  introduced  through  these,  readily  reaches  bare  and 
dead  bone. 

The  patient^s  general  healtli  has  by  this  time  become 
seriously  affected,  owing  both  to  the  actual  suffering  he  has 
undergone,  and  to  the  interference  with  his  nutrition  which 
the  state  of  his  mouth  necessarily  involves  ;  it  being  im- 
possible for  him  to  take  any  but  fluid  or  semi-fluid  food, 
and  that  in  small  quantities.  The  constant  presence  of 
most  offensive  discharges  in  the  mouth,  and  mixing  with  the 
food,  must  have  an  injurious  effect  upon  the  patient,  though 
this  is  questioned  by  Salter,  who  remarks  that  these  patients 
swallow  daily  many  ounces  of  pus  "without  any  obvious 
detriment  to  health."  The  necrosed  portions  of  bone  pro- 
ject more  or  less  into  the  mouth,  and  give  the  patient  great 
inconvenience,  and  in  very  severe  cases  of  phosphorus-necro- 
sis gangrene  of  the  cheeks  and  lips  ensues,  with  a  rapidly 
fatal  termination.  In  less  severe  cases,  the  patient  may 
drag  on  a  wretched  existence  for  months,  and  sink  at  last 
from  exhaustion,  or  may  occasionally  recover  with  consider- 
able loss  of  bone  and  deformity. 

Advanced  necrosis  of  the   upper  jaw  may  lead  to  exten- 


12(3  NECROSIS    OF   THE    JAWS. 

sion  of  mischief  to  the  brain  with  a  fatal  result,  as  I  have 
myself  seen  on  one  occasion.  The  patient  was  a  young- 
woman,  aged  twenty-three,  in  whom  necrosis  of  the  upper 
jaw  had  existed  for  nine  months,  when  head  symptoms 
supervened,  and  she  rapidly  sank  and  died  comatose.  At 
the  post-mortem  examination,  I  found  an  abscess  in  the 
anterior  lobe  of  the  cerebrum,  evidently  originating  from  the 
ethmoid  bone,  the  cribriform  plate  of  which  was  necrosed 
and  perforated. 


127 


CHAPTER    IX. 

KEPAIR  AFTER  NECROSIS TREATMENT  OF  NECROSIS. 

It  has  been  already  remarked  under  the  head  of  Exauthe- 
niatous  iSTecrosis,  that  in  young  subjects  a  development  of 
fibrous  tissue  takes  place  after  loss  of  substance  in  the  upper 
jaw.  This  is  not  the  case  when  loss  of  part  of  the  superior 
maxilla  takes  place  in  adult  life,  except  in  rare  instances,  it 
being  remarkable  that  the  periosteum  of  tlie  upper  jaw 
ordinarily  makes  no  effort  at  repairing,  by  effusion,  the 
mischief  which  has  taken  place.  M.  Oilier,  of  Lyons,  in 
his  very  valuable  work  "  La  Et'g^neration  des  Os,"  (1867) 
gives  a  case  of  phosphorus-necrosis  of  tlie  upper  jaws 
where  a  certain  amount  of  new  bone  was  produced,  and  also 
one  of  necrosis  of  the  upper  jaw  from  other  causes,  in  wliich 
a  development  of  osteo-fibrous  tissue  took  place  in  a  young 
woman  of  nineteen.  He  quotes  also  from  the  practice  of 
Billroth,  of  Zurich,  the  case  of  a  man,  aged  twenty-seven,  in 
whom,  after  phosphorus-necrosis,  a  development  of  plates  of 
bone  took  place.  These  cases  must  be  regarded,  however, 
as  quite  exceptional,  Trelat  in  his  thesis  (1857),  having  failed 
to  discover  a  case  of  osseous  reproduction  of  the  superior 
maxilla.  In  the  lower  jaw,  however,  the  case  is  very  dif- 
ferent, the  periosteum  and  the  surrounding  tissues  being 
very  active  in  producing  new  bone,  to  take  the  place  even- 
tually of  that  which  is  necrosed. 

So  soon  as  the  periosteum  is  separated  from  tlie  jaw 
by  the  formation  of  pus  around  the  sequestrum,  it  appears 
to  take  on  an  active  condition  which  leads  to  the  effu- 
sion of  plastic  lymph.  This  becomes  rapidly  converted 
into  fibro-cartilage  and  then  iuto  bone,  which  forms  a 
more  or  less  complete  shell  around  the  necrosed  portion. 
Through  the  cloacce,  or  openings  in  this   new  shell  of  bone, 


128  REPAIR    AFTER    NECROSIS. 

which  correspond  to  the  external  apertures  on  the  skin, 
and  also  from  the  mouth,  the  dead  bone  or  sequestrum  can 
be  readily  examined  with  the  probe,  and,  when  sufficiently 
detached  arid  loosened  to  be  readily  extracted,  it  should  be 
removed  if  possible  through  the  mouth  so  as  to  avoid  de- 
formity from  an  external  wound.  It  is  of  importance  that 
this  removal  should  not  be  undertaken  until  the  shell  of 
new  bone  is  sufficiently  organized  to  maintain  the  sliape  of 
the  original  bone,  for  if  otherwise,  the  reproduction  of  the 
bone  will  be  interfered  with,  and  perhaps  prevented.  So 
soon  as  the  sequestrum  is  removed  from  the  interior  of  the 
shell  of  new  bone,  the  space  thus  left  becomes  rapidly  filled 
with  granulations  springing  up  from  the  whole  surface  of 
the  cavity,  and  these  are  soon  converted  into  a  fibrous  mass 
which  is  ultimately  developed  into  bone.  In  1869  I  had 
under  my  care  in  University  College  Hospital  a  case  of 
necrosis  of  nearly  the  entire  lower  jaw  in  a  man  of  twenty- 
two,  from  whose  mouth  I  extracted  several  large  sequestra, 
including  the  right  condyle.  In  this  case,  and  in  others  of 
the  kind  which  I  have  seen,  the  repair  has  been  of  the  most 
perfect  kind,  the  movements  of  the  jaw  being  as  free  as  if 
the  articulation  had  not  been  interfered  with.  The  details  of 
the  case  will  be  found  in  the  Appendix  (Case  VI.), 

In  the  Mcdico-Chirurgieed  Trems.,  vol.  Ivii.,  is  a  case  of 
phosphorus-necrosis,  reported  by  Mr.  Savory,  in  which,  six 
months  before  the  death  of  the  patient,  a  lad  of  eighteen, 
the  whole  of  the  lower  jaw  was  extracted,  and  is  preserved 
in  St.  Bartholomew's  Museum  (I.  232).  Althougli  "  at  this 
time  there  was  not  sufficient  firmness  in  any  part  of  the 
region  to  indicate  the  formation  of  new  bone,  yet  in  the 
course  of  a  week  or  two  afterwards  there  was  distinct  evi- 
dence of  new  bono  on  either  side  about  the  angle,  which 
gradually  extended."  The  new  lower  jaw  which  had  been 
formed  is  shown  in  fig.  52,  and  is  perhaps  one  of  the  most 
perfect  specimens  of  the  kind  ever  seen.  "  In  size,  sliape, 
and  development  it  is  very  remarkable.  The  bone  is  solid 
and  dense  and  in  two  pieces  only.  The  greater  portion 
constitutes  the  wliole  of  the  bone,  with  the  exception  of  the 


REPAIR   AFTER   NECROSIS. 
'^        ^^  I     :.  52. 


129 


130  REPAIR   AFTER   NECROSIS. 

right  ramus.  This  was  united  to  the  body  by  fibrous  tissue, 
and  separated  during  maceration.  In  size  and  form,  and 
especially  in  the  absence  of  alveolar  portions,  the  jaw  very 
nearly  resembles  the  edentulous  maxilla  of  a  very  old  person, 
as  shown  in  fig.  53.- 

In  the  St.  Bartliolomcv)s  Hospital  Reports,  voL  i.  (1865), 
a  very  remarkable  case  of  restoration  of  the  lower  jaw  is 
described  by  Mr.  Thomas  Smith,  to  whom  I  was  indebted 
for  the  original  drawing  of  the  preparations  in  the  hospital 
museum  which  accompanied  this  essay.  The  case  w\as  one 
of  necrosis  of  the  entire  lower  jaw  in  a  lucifer-match  maker, 
but  not  presenting  the  peculiar  pathological  condition  of 
pumice-stone  deposit  upon  the  sequestrum,  which  is  charac- 
teristic of  the  phosphorus  disease  and  will  be  afterwards  re- 
ferred to.  Mr.  Smith  removed  the  sequestrum  of  the  entire 
jaw  in  two  pieces  (St.  Bartholomew's  Museum,  I.  233),  and 
the  patient  went  out  of  tlie  hospital  at  the  end  of  six  weeks, 
but  died  suddenly  the  next  day. 

The  following  is  Mr.  Smith's  description  of  the  repair  : — 
"  The  new  bone  was  situated  in  front  of  and  on  a  lower 
plane  tlian  the  bone  it  replaced  ;  it  was  distinctly  embedded 
in  the  soft  parts  between  the  anterior  layer  of  the  peri- 
osteum of  the  old  jaw  and  the  integuments  of  the  face. 
The  relative  position  of  the  old  and  new  bone  is  shown  in 
the  drawing.  On  the  posterior  aspect,  some  of  the  fibrous 
texture  of  the  gum  has  been  left  so  as  to  show  a  groove  in 
the  soft  parts,  which  was  originally  occupied  by  the  dead  bone. 
This  groove  had  very  greatly  diminished  in  size  before  the 
patient's  death,  and  has  still  further  shrunk  by  maceration 
in  spirit. 

The  temporal  muscle  was  found  attached  to  the  coronoid 
process  ;  the  masseters  were  blended  with  the  outer  surface 
of  the  angle  and  ramus  of  each  side  ;  while,  behind  the  sym- 
physis, there  may  still  be  seen  in  the  specimen  tlie  remains 
of  the  genio-hyoid,  genio-hyoglossi,  and  digastric!.  No  other 
muscles  were  found  attached  t<j  the  bone.  The  inferior 
dental  nerves  were  found  lying  in  the  fibrous  texture  of  the 
old  gum.     There  is  apparently  no  provision  for  them  in  the 


SPECIMEN    OF   REPAIR.  131 

new  jaw,  from  wliicli  they  lay  quite  separated  by  both  layers 
of  the  periosteum  of  the  necrosed  jaw. 

Tlie  new  bone  consisted  chiefly  of  three  portions,  of  wliich 
two  are  formed- by  the  coronoid  x^rocess  and  condyle  together, 
of  either  side  ;  whilst  the  third  and  largest  portion  repre- 
sents tlie  right  ascending  ramus,  the  angle,  horizontal  ramus, 
and  symphysis,  and  extends  as  far  as  tlie  position  of  the 
eye-tooth  on  the  left  side.  The  part  of  the  jaw  that  is 
wholly  deficient  in  bony  structure  is  included  between  the 
position  of  the  eye-tooth  and  last  molar  of  the  left  side.  The 
parts  in  which  most  bone  is  found  being  apparently  those 
points  where  ossification  commenced,  on  the  coronoid  pro- 
cesses, the  angles,  and  especially  the  neighbom-hood  of  the 
symphysis,  where  the  bone  is  more  abundant,  denser  in  its 
structure,  and  more  perfectly  formed  than  elsewhere. 

The  newly-formed  jaw,  on  microscopic  examination,  shows 
all  degrees  of  development,  from  a  finely  fibro-nuclear 
matrix  up  to  perfect  bone.  The  bone  differs  from  ordinary 
compact  bone  in  being  excessively  vascular,  the  Haversian 
canals  being  very  large,  near  together,  freely  anastomosing, 
and  here  and  there  in  their  wall  presenting  fusiform  and 
pouch-like  dilatations,  in  fact,  resembling  in  their  outlines 
veins  slightly  varicose. 

The  bone  is  thickly  studded  with  lacunae,  and  these  are 
peculiar  in  being  very  large  in  their  ca\'ities,  less  uniform  in 
their  general  outline,  and  bearing  fewer  caualiculi  than  is 
usual  in  well-formed  bone.  In  the  newest  parts  of  the  bone 
the  lacuna?  are  merely  irregularly  formed  cavities  without 
distinct  canaliculi. 

From  the  relation  of  the  dead  bone  to  the  soft  parts, 
lying  as  it  did  in  a  fossa  formed  by  the  gaping  gums,  from 
the  relation  of  this  fossa  to  the  new  bone,  as  seen  in  the 
specimen,  it  is  evident  that  the  regeneration  of  bone  in  this 
case  did  not  take  place  from  the  osseous  surface  of  the  peri- 
osteum, but  rather  from  the  fibrous  structure  of  the  gum  in 
front  of  the  original  jaw.  The  only  portion  of  bone  in  this 
case  formed  directly  from  the  detached  periosteum,  was  re- 
moved at  the  time  of  the  operation,  and  may  be  seen  in  the 

K  2 


132  REPAIR   AFTER   NECROSIS. 

necrosed  jaw  adhering  to  the  ramus  and  angle  of  the  left 
side.  It  formed  no  part  of  that  system  of  bone  formation 
which  eventually  reproduced  the  jaw." 

This  case  is  remarkable  in  more  ways  than  one.  In  the 
first  place,  the  absence  of  the  pumice-like  deposit  upon  the 
sequestrum  would  appear  to  exclude  it  from  the  category  of 
phosphorus-necrosis,  but  the  patient  was  undoubtedly  ex- 
posed to  the  action  of  phosphorus,  and  it  will  be  shown  at  a 
later  jDeriod  that  this  deposit  is  not  of  necessity  connected 
with  phosphorus.  The  second  notable  point  is,  that  according 
to  Mr.  Smith's  description  the  reparative  material  was  formed 
not  around,  but  entirely  in  front  of  or  below  the  sequestrum. 
The  third  point,  still  more  remarkable,  is,  that  if  Mr.  Smith's 
observation  is  correct,  the  new  structure  was  entirely  outside 
the  periosteum  of  the  jaw,  and  was  derived  entirely  from  the 
surrounding  soft  parts. 

Mr.  Smith  is  too  accurate  an  observer  to  have  been  de- 
ceived by  the  appearances,  and  we  must  conclude,  therefore, 
that  not  only  was  the  bone  killed  by  the  action  of  the  poison, 
but  that  tlie  periosteum  also  lost  its  vitality  to  such  an  ex- 
tent that  it  was  unable  to  secrete  that  pumice-like  bone 
usually  found  in  these  cases,  or  to  assist  in  any  way  to  form 
reparative  material.  That  the  surrounding  soft  parts  should 
under  these  circumstances  have  assumed  the  reparative  func- 
tion to  the  extent  tliey  did,  is  a  remarkable  instance  of  the 
adapting  powers  of  Nature. 

In  commenting  upon  the  above  case,  Mr.  Smith  expresses 
an  opinion  that  "  of  late  tlie  office  of  the  periosteum  as  an 
osteogenetic  membrane  has  been  much  magnified  at  the  ex- 
pense and  to  the  disparagement  of  other  sources  of  bone  re- 
production." M.  Oilier,  on  the  other  hand^  whose  physio- 
logical researches  on  the  nature  of  periosteum  are  well 
known,  in  his  work  already  alluded  to,  strongly  maintains  the 
bone-producing  power  of  the  periosteum  and  advises  its  pre- 
servation where  possible ;  giving  cases  where  this  has  been 
followed  by  the  reproduction  of  bone,  as  has  been  frequently 
witnessed  in  England.     The  question  of  the   so-called  sub- 


RETENTION  OF  THE  TEETH.  133 

periosteal   resection  will  be  discussed    under  the   head   of 
Treatment  of  Necrosis. 

Whatever  the  tissue  from  which  the  bone  is  reproduced, 
there  can  be  no  question  as  to  the  fact  of  its  reproduction 
in  the  majority  of  instances  of  necrosis  of  the  lower  jaw. 
Even  when,  as  in  my  own  case  already  mentioned^  the  condyle 
with  a  large  portiou  of  the  ramus  of  the  jaw  is  necrosed, 
complete  repair  has  been  found  in  young  subjects.  Stanley, 
however,  quotes  a  case  of  this  kind  from  Desault,  as  one 
"  of  the  least  frequent  examples  of  the  reproduction  of  bone 
consequent  on  necrosis,"  and  refers  to  one  recorded  by  Mr. 
Syme.  As  additional  examples  may  be  quoted  one  by  the 
late  Mr.  H.  Gray  {Pathological  Transactions,  vol.  ii.), 
wliich  occurred  in  the  practice  of  Mr.  Keate,  and  one  by  Dr. 
Cooper,  of  San  Francisco,  which  has  been  already  referred 
to.  A  case  of  sub-periosteal  resection  of  one  half  of  the  jaw 
by  M.  Maisonneuve,  in  which  complete  repair  took  place, 
will  be  referred  to  further  on.  On  the  other  hand  it  should 
be  remarked  that  several  instances  of  non-repair  of  lost 
bone  have  been  recorded.  Thus  Stanley  mentions  a  case 
under  the  care  of  Mr.  Perry,  which  will  be  referred  to  again, 
in  which  no  repair  took  place  ;  and  three  similar  cases  are 
to  be  found  in  South's  Chelius.  Also  in  the  Lancet,  25th 
January,  1862,  it  is  mentioned  that  a  patient  from  whom 
Mr.  T.  Wakley  removed  an  extensive  necrosis  in  1857,  was 
at  that  time  to  be  seen  about  the  streets  exhibiting  himself 
for  a  livelihood,  and  everting  his  mouth  to  show  that  his 
lower  jaw  was  absent. 

A  remarkable  feature  in  Mr.  Perry's  case,  already  men- 
tioned, was,  that  though  the  entire  jaw  was  necrosed  and 
removed,  yet  "  nearly  all  the  teeth  remained  in  the  mouth, 
and  were  kept  together  by  their  connexion  with  the  gum  ;" 
and  according  to  Mr.  Stanley,  the  patient  "  chewed  her  food 
by  a  movement  of  the  upper  jaw  (?),  aided  by  the  action  of 
the  tongue  in  rubbing  the  morsel  against  the  teeth."  Ex- 
traordinary as  it  appears,  that  the  teeth  should  thus  remain 
in  situ,  the  fact  is  undoubted,  and  is  confirmed  by  other 
examples  :  thus,  Mr.  Sharp,  of  Bradford  {Medico- Chirurgical 


134  REPAIR   AFTER   NECROSIS. 

Transactions,  vol.  xxvii.),  removed  a  large  sequestrum  from  a 
young  woman,  aged  twenty,  through  an  incision  beneath  the 
chin,  and  all  the  teeth  remained  firm.  In  the  Medical  Thncs 
and  Gazette  of  October  30th,  1858,  also,  it  is  mentioned  that 
Mr.  Skey  brought  before  the  students  of  St.  Bartholomew's 
a  young  man  of  twenty,  from  whom,  four  months  before^  he 
had  removed  a  sequestrum  including  the  entire  left  side  of 
the  jaw  from  the  ramus  to  the  symphysis,  and  the  right  side 
as  far  as  the  last  molar  tooth.  The  sequestrum  showed  the 
sockets  of  twelve  teeth — viz.,  all  those  of  the  left  side,  and  the 
incisors,  canine,  and  first  bicuspid  of  the  right  side ;  but  tlie 
whole  of  the  alveolar  border  of  the  right  side  was  not  pre- 
sent in  the  sequestrum.  Instead  of  coming  away  with  the 
bone,  the  incisors,  canine,  and  first  bicuspid  of  the  right  side, 
and  even  the  left  central  incisor  had  remained  in  the  gum. 
The  patient  now  applied  to  Mr.  Skey  to  have  these  teeth 
removed,  as,  although  they  evidently  ])ossessed  vitality  and 
were  firmly  attached  to  the  gums,  they  had  sunk  in  position 
so  as  to  be  irregular  and  inconvenient.  I  have,  however, 
seen  one  case  in  which  the  teeth  remained  firm  and  useful 
after  extensive  necrosis  ;  but  in  this  case  the  sequestrum  in- 
volved only  the  outer  plate  of  the  jaw,  the  inner  with  a 
great  part  of  each  socket  being  left  for  the  support  of  the 
fangs  of  the  teeth. 

An  observation  of  Mr.  Salter's  {System  of  Simjcry,  vol.  ■ 
ii.)  deserves  notice,  and  it  received  confirmation  from  one 
of  the  cases  recorded  by  Mr.  Chalk  in  the  paper  already 
referred  to.  He  says,  "  Tliough  it  has  not  been  stated  in 
books,  this  repair  of  the  lower  jaw  is  but  temporary,  for 
after  a  time — often  a  considerable  time — the  new  bone 
diminishes  by  absorption  to  a  mere  arch,  and  ultimately  there 
is  scarcely  enougli  bone  to  keep  out  the  lower  lip,  and  the 
chin  is  utterly  lost.  I  have  had  an  opportunity  of  examin- 
ing this  state  of  parts  after  the  lower  jaw  had  been  removed 
ten  years.  How  far  this  loss,  by  absorption  of  supplemental 
bone,  may  be  prevented  by  supplying  it  with  a  function 
through  the  means  of  artificial  teeth,  is  a  question  of  theo- 
retical interest  and  of  practical  importance." 


THE   PUMICE-LIKE   DEPOSIT.  135 

One,  almost  constant,  pathological  peculiarity  in  cases  of 
phosphorus-necrosis  has-been  already  alluded  to,  and  deserves 
special  notice  ;  it  is  the  deposit  of  a  peculiar,  pumice-like, 
bony  material  around  the  necrosed  portions  of  the  lower 
jaw,  for  it  is  not  found  in  cases  of  disease  of  the  upper  jaw. 
This  is  doubtless  derived  from  the  periosteum,  although  so 
closely  adlierent  to  the  sequestrum  as  to  be  invariably 
brought  away  with  it ;  and  though  resembling  true  bone  in 
some  particulars,  it  is  decidedly  of  a  lower  development. 

According  to  Von  Bibra  {oiJ.  cit),  who  has  laboriously 
investigated  the  subject  microscopically,  the  Haversian 
canals  exhibit  in  part  a  larger  diameter  than  those  of  normal 
bone  and  are  empty,  except  where  the  deposit  appears 
smooth  and  compact,  and  is  partially  covered  with  periosteum. 
They  are  not  paralhl  with  the  general  direction  of  the  bone, 
but  are  placed  at  right  angles  to  the  latter  ;  they  interlace 
with  one  another,  sometimes  expanding  to  form  sacs,  some- 
times contracting,  and  end  with  open  mouths  on  the  surface. 
Their  mouths  are  more  minute  in  the  most  recent  deposit, 
and  appear  larger  in  older  layers.  The  bone  corpuscles 
are  rounded  off  or  angular,  and  their  circumference  is  less 
decided ;  during  the  progress  of  the  formation  of  the  deposit 
they  are  very  large,  and  their  contour  proportionably  unde- 
fined. They  appear  filled  and  dark- coloured  ;  at  first  they 
are  lighter  and  they  have  ramifications  like  those  of  normal 
bone,  which  increase  in  number  with  the  age  of  the  deposit. 
The  fundamental  structure  of  the  deposit  is  laminated,  and 
several  layers  are  distinctly  seen  resting  upon  one  another. 
It  exhibits  rents  with  which  the  ramifications  of  the  cor- 
puscles are  connected,  and  which  may  therefore  be  con- 
sidered as  continuations  of  the  latter.  Spots  are  also  visible 
here  and  there,  which  Von  Bibra  looks  upon  as  accumula- 
tions of  earthy  matter.  This  matrix  of  the  new  deposit  is 
at  first  very  brittle ;  after  the  deposit  has  been  exposed  to 
the  process  of  absorption  it  shows  a  powdery  appearance,  as 
if  sprinkled  with  a  coarse  powder. 

This  description  of  the  microscopic  appearances  may  be 
advantageously  contrasted   with  that  of  the   new  bone  in 


136  REPAIR   AFTER   NECROSIS. 

Mr.  T.  Smith's  case  of  restoration  of  the  jaw  (p.  131),  of 
wliich  tlie  Haversian  canals  were  jDarallel  to  those  of  the  ori- 
ginal bone  instead  of  being  at  right  angles  to  them,  which 
is  such  a  marked  peculiarity  of  the  pumice-like  deposit. 

It  appears,  however,  that  cases  of  necrosis  other  than 
those  due  to  phosphorus  occasionally  lead  to  a  deposit  of 
pumice-like  bone  upon  the  sequestrum.  Mr.  Perry's  case 
of  necrosis  of  the  entire  lower  jaw,  already  alluded  to  (and 
which  will  be  found  in  extenso  in  the  Medico-Ghirurgi<:al 
Transactions,  vol.  xxi.),  is  a  case  in  point,  the  sequestrum, 
as  may  be  seen  from  the  drawing  given  of  the  prepa- 
ration in  St.  Bartholomew's  Museum,  being  thickly  en- 
crusted with  new  bone,  closely  resembling  that  seen  in 
phosphorus  cases.  The  disease  in  this  case  was  attributed  to 
rheumatism^  and  corresponds  very  closely  to  the  description 
given  by  Dr.  Senftleben  of  the  later  stages  of  acute  rheu- 
matic periostitis.  (See  p.  108.)  He  says,  "  Spontaneous 
separation  of  the  sequestrum  rarely  ensues  ;  it  remains  to 
some  extent  in  organic  connection  with  the  osteophytes,  and 
ultimately,  after  a  number  of  months,  a  year,  or  even  more, 
an  operation  has  to  be  performed,  in  which  both  the  seques- 
trum and  the  osteophytes  are  removed  together."  So  far  as 
I  am  aware,  the  new  bone  in  Mr.  Perry's  case  has  not  been 
submitted  to  microscopic  examination. 

A  preparation  in  the  College  of  Surgeons  Museum  (1442) 
bears  upon  this  question.  It  is  a  portion  of  the  lower  jaw  of 
a  girl  fet.  ten,  consisting  of  the  condyle  and  part  of  tlie  ramus 
and  the  coronoid  process  (separate),  for  which  I  was  in- 
debted to  Mr.  Lawson.  The  symptoms  were  those  of  ne- 
crosis, tliere  being  abscess,  &c. ;  and  in  December,  1866,  that 
gentleman  cut  down  upon  the  seat  of  the  disease  and  re- 
moved those  portions  which  were  separated  from  the  rest  of 
the  bone.  The  preparation  shows  the  ramus  of  the  jaw  at 
the  lower  part  of  normal  thickness  and  apparently  necrosed, 
but  at  the  upper  part  there  is  around  it  a  deposit  of  new 
bone,  very  closely  resembling  the  pumice-stono  deposit  of 
phospliorus-necrosis.  A  portion  of  this  lias  been  detached, 
but  it  may  Ije  observed  that  the  articular  cartilage  is  perfect. 


THEATMENT   OF   NECROSIS.  137 

and  the  puiiosteiun  near  it  healthy,  although,  owing  to  the 
new  deposit,  the  condyle  and  neck  of  the  jaw  are  greatly 
altered  in  shape.  This  appears  to  me  to  have  been  a  case 
of  Ostitis  rather  than  Periostitis,  the  deposit  resembling 
that  found  under  such  circumstances  ;  and  the  fact  of  the  de- 
posit taking  place  beneath  the  apparently  healthy  periosteum, 
would  appear  to  point  to  the  same  solution  of  the  question. 

Treatment  of  Necrosis. — In  the  early  inflammatory  stage 
of  the  disease,  it  is  obviously  of  the  first  importance  to  get 
rid  of  any  local  cause  which  may  be  exciting  or  keeping 
up  irritation,  and  therefore  any  diseased  teeth  or  stumps 
should  be  immediately  extracted,  and  the  patient  should 
be  removed  from  the  action  of  any  local  irritant,  such  as 
the  fumes  of  phosphorus.  Local  abstraction  of  blood  by 
leeches,  both  externally  and  internally,  and  by  scarifica- 
tion of  the  gums,  will  relieve  the  congestion ;  and  the 
application  of  emollient  poultices  externally,  and  of  poppy 
fomentations  in  the  mouth,  will  relieve  the  pain.  The 
bowels  having  been  cleared,  iodide  of  potassium  should  be 
had  recourse  to  in  full  doses,  according  to  the  age  of  the 
patient,  combined  with  opium  if  there  is  much  pain  and 
restlessness. 

By  these  means  the  disease  may  be  prevented  from  pro- 
ceeding beyond  the  stage  of  periostitis,  but  if  from  the 
swelling  of  the  parts  about  the  jaw  it  is  to  be  feared  that 
the  destruction  of  the  bone  is  probable,  free  incisions  should 
be  made  within  the  mouth  down  to  the  bone,  to  give  exit  to 
effusion,  and  thus,  if  possible,  avert  the  death  of  the  bone, 
after  which  the  treatment  above  recommended  should  be 
pursued  with  assiduity.  When  necrosis  has  actually  taken 
place,  and  pus  has  formed  around  the  jaw,  its  tendency  to 
the  surface  is  so  great  that,  if  free  exit  for  it  is  not  made 
within  the  mouth,  it  will  cause  sinuses  externally,  and  give 
rise  to  great  disfigurement.  Free  incisions  should  therefore 
be  made  through  the  gums,  but  without  disturbing  the  eftbrts 
at  repair  if  they  are  already  in  progress.  As  all  hope  of 
arresting  the  disease  must  now  be  abandoned,  it  is  useless 
to  continue  the  administration  of  drugs  except  as  general 


138  TREATMENT   OF   NECROSIS. 

tonics,  and  at  the  same  time  every  effort  must  be  made  to 
support  the  patient's  strength  by  suitable  diet.  Since  it  is 
impossible  that  the  patient  should  masticate  solid  food,  it 
is  important  that  animal  food  should  be  prepared  in  a 
suitable  manner,  and  this  may  be  attained  by  making  use 
of  soups  or  essences  of  meat,  and  by  reducing  well-cooked 
meat  to  a  mash  with  pestle  and  mortar.  Milk  and  eggs 
form  very  suitable  articles  of  food,  and  must  be  supplemented 
with  wine  or,  better,  stout. 

The  offensive  discharges  constantly  present  in  the  mouth 
must  be  combated  with  detergent  gargles  of  chlorinated 
soda  or  permanganate  of  potash,  and  when  the  patient  is 
unable  to  cleanse  his  mouth  satisfactorily  by  his  own  efforts, 
it  should  be  mopped  out  with  small  sponges  affixed  to  a 
handle,  assisted  by  the  use  of  a  syringe. 

Most  British  surgeons  agree  in  counselling  non-inter- 
ference with  the  sequestra  in  cases  of  necrosis  until' the 
shell  of  new  bone  around  is  sufficiently  developed  to  main- 
tain the  form  of  the  jaw ;  they  are  then  to  be  extracted 
through  the  mouth,  if  possible,  and  if  not,  through  incisions, 
placed  so  as  to  cause  as  little  subsequent  deformity  as 
possible.  When  the  sequestrum,  although  partially  de- 
tached, is  not  ready  for  removal,  and  greatly  inconveniences 
the  patient,  a  part  may  be  clipped  off  with  the  bone  forceps, 
so  as  to  present  a  smooth  surface,  and  if  the  teeth  are  loose 
and  troublesome  they  had  better  be  removed  at  once,  but  if 
firm  they  should  be  left,  since,  as  has  been  shown,  they 
occasionally  become  useful.  The  caution  already  given 
against  interfering  with  the  permanent  set  of  teeth  in  cases 
of  necrosis  in  children  should  be  borne  in  mind. 

Some  continental  surgeons,  however,  interfere  at  any 
early  date,  and  among  them  Professor  Billroth,  who,  accord- 
ing to  the  report  of  the  meeting  of  the  Medical  Congress  at 
Zurich  in  1861  {Medical  Times  mid  Gazette,  June  8,  1861), 
"  penetrates  inmiediately,  with  one  incision,  which  he  makes 
parallel  to  the  necrotic  part,  through  the  skin  down  to  the 
bone  ;  he  then  scrapes  oif  the  periosteum  with  its  bony 
layers  upwards  and  downwards,  by  means  of  a  raspatorium. 


SUB- PERIOSTEAL   RESECTION.  139 

and  saws  smaller  or  larger  pieces  of  bone  out  of  tlie  jaw; 
or  lie  nips  those  pieces  off  by  means  of  bone-pincers.  In 
a  few  cases  it  appeared  advisable  to  disarticulate  at  once 
one  or  both  coronoid  and  condyloid  processes  of  the  lower 
jaw,  which  was  very  easily  done,  as  the  joint  had  become 
very  loose  in  consequence  of  the  long  suppuration.  Of  the 
six  cases  shown  by  the  Professor,  two  were  healed,  and 
amongst  them  was  one  of  total  resection  of  the  jaw  in  a 
woman  of  thirty-five  years.  This  case  was  in  so  far  re- 
markable, as  two  apparently  healthy  teeth  had  remained  in 
the  periosteum,  which  had  become  partly  ossified,  and  in  the 
gums,  which  had  remained  healthy ;  and  these  have  now 
been  used  for  seven  months.  Mastication  is  not  impaired, 
and  the  woman  has  a  much  healthier  appearance.  The 
second  case  in  which  the  resection  of  one-half  of  the  jaw 
was  performed,  is  also  well  healed  ;  but  the  mouth  is,  of 
course,  crooked.  Two  cases,  in  which  a  partial  resection  has 
been  made,  are  progressing  favourably ;  in  another  case  the 
treatment  with  mercury  and  iodine  has  been  commenced." 

When  the  whole  lower  jaw  is  necrosed  it  is  necessary  to 
divide  it  before  it  can  be  extracted.  This  may  be  done,  as 
in  Mr.  Perry's  case,  by  making  a  section  with  the  saw  near 
the  angle  on  each  side,  or,  better,  by  dividing  with  the  saw 
at  the  symphysis,  either  without  external  incision,  as  in  Mr, 
T.  Smith's  case,  or  after  reflecting  flaps  of  skin,  as  in  a  case 
of  Sir  J.  Paget's,  which  will  be  found  in  the  Lancet,  1862.  In 
a  case  of  necrosis  of  the  entire  lower  jaw,  from  phosphorus, 
which  was  in  the  London  Hospital  under  Mr.  Adams'  care, 
that  gentleman  preferred  to  divide  the  symphysis  with  a 
mallet  and  chisel,  and  the  case  is  moreover  remarkable  from 
the  unusual  occurrence  of  secondary  haemorrhage,  for  which 
ligature  of  the  common  carotid  became  necessary — the 
patient  eventually  recovering.  The  case  will  be  found  in 
detail  in  the  Medical  Times  and  Gazette,  1863. 

Under  tlie  name  of  "  Sub-periosteal  Eesection,"  operations 
have  been  described  by  foreign  surgeons^  which  in  no  re- 
spect differ  from  the  extraction  of  sequestra  as  ordinarily 
practised,  and  of  which  the  following  case,  taken  from  the 


140  TREATMENT    OF    NECROSIS. 

Lancet,  of  1863,  is  a  good  example  : — "  M.  Eizzoli,  of 
Bologna,  submitted  to  the  Surgical  Society  of  Paris  a  case 
of  necrosis  of  the  lower  jaw,  from  the  fumes  of  phosphorus, 
in  a  man  aged  fifty-six  years,  in  which  the  sequestra  were 
removed  through  the  mouth.  M.  Eizzoli  made  incisions  on 
either  side  of  the  gums,  scraped  the  thickened  periosteum 
with  a  spatvila  from  the  dead  bone,  and  removed  the  latter 
piecemeal.  The  preserved  periosteum  generated  new  bone 
in  the  place  of  the  portions  taken  away,  which  comprised 
the  body  and  part  of  the  ramus  on  each  side.  It  was,  how- 
ever, soon  found  that  the  upper  part  of  the  ramus  and  the 
condyle  were  also  diseased  ;  these  portions  of  bone  were  also 
removed  through  the  mouth  with  the  same  precautions,  and 
the  periosteum  again  acted  in  the  same  way.  Eventually 
the  man  was  able  to  use  his  jaw,  and  masticate,  though  de- 
prived of  teeth.  M.  Forget,  who  reported  on  the  case, 
observed,  very  justly,  that  there  was  nothing  new  in  the 
action  of  the  j)eriosteum  in  necrosis  of  bones,  surgeons  having 
long  acted  upon  this  periosteal  property  in  such  cases,  M. 
riourens  had  pointedly  said,  '  Take  away  the  bone,  preserve 
the  periosteum,  and  the  preserved  periosteum  will  restore  the 
bone  ;'  but  tliis  applies  less  to  cases  of  necrosis  of  bone  than 
to  cases  of  experiments  on  animals  and  operations  performed 
on  healthy  bone  and  periosteum.  And  even  in  these  cases 
it  should  be  remembered  that  osseous  substance  is  reproduced, 
but  not  the  actual  bone  as  it  existed  before  the  resection." 
In  some  cases,  however,  incisions  have  been  made  at  a  com- 
paratively early  stage,  before  the  shell  of  new  bone  has  been 
formed,  and  tlie  sequestrum  immediately  extracted,  with 
good  results.  It  may  be  doubted,  however,  whether  there 
is  any  real  gain  in  such  procedures,  either  in  time  or  result, 
since  the  repair  is  no  more  rapid  than  if  the  sequestrum 
were  left,  and  there  is  the  additional  risk  both  of  the  actual 
operation,  and  of  the  deformity  which  may  result  from  the 
premature  withdrawal  of  the  sequestrum.  A  case  from  the 
practice  of  M.  Maisonneuve,  illustrating  the  practice  in 
the  lower  jaw,  will  be  found  in  the  Compln^  llrmivs,  April, 
1861.      In   his  standard  work,  "  La  Kegeneration  des   Os," 


PREVENTION   OF   PHOSPHORUS-NECROSIS.         141 

M.  Oilier,  of  Lyons,  gives  two  cases  of  subperiosteal  re- 
section, one  of  the  upper  and  one  of  the  lower  jaw,  for 
necrosis,  in  neither  of  which  was  there  any  osseous  develop- 
ment ;  and  these  cannot,  therefore,  be  regarded  as  very 
satisfactory  examples  of  a  proceeding  whose  great  aim  is  the 
development  of  new  bone. 

With  regard  to  the  prevention  of  phosphorus-necrosis,  the 
following  extract  from  Mr.  Simon's  report  to  the  Privy 
Council  (1863),  may  be  quoted  with  advantage,  as  giving 
the  results  of  Dr.  Bristowe's  careful  investigation  of  the 
subject : — "  The  dangers  to  which  I  have  adverted,  as 
belonging  to  the  phosphorus  industry,  belong  exclusively  to 
working  with  common  phosphorus.  Working  with  amor- 
phous phosphorus  is  unattended  with  danger  to  health. 
Since,  however,  it  appears  that,  with  reasonable  precautions, 
the  use  of  common  phosphorus  for  match-making  need  not 
be  an  unwholesome  occupation,  I  cannot  say  that,  in  my 
opinion,  the  substitution  of  amorphous  for  common  phos- 
phorus in  the  manufacture  is,  for  sanitary  purposes,  an  object 
to  be  unconditionally  insisted  on.  Yet  having  regard  to  the 
fact  that  amorphous  phosphorus  not  only  is  manufactured 
without  danger  to  the  worker,  but  that  its  use  in  lucifer 
boxes  also  involves  infinitely  less  danger  of  fire  than  belongs 
to  common  lucifer  matches,  I  think  that  the  substitution  is 
alto£^ether  one  to  be  desired.  And,  of  course,  with  reference 
to  any  restriction  which  the  legislature  might  think  of  im- 
posing on  the  utilization  of  common  phosphorus,  it  would 
deserve  to  be  remembered  that  manufacturers  would  have  at 
their  option  the  alternative  of  using,  without  restriction,  the 
innocuous  amorphous  material." 


142 


C  H  A  P  T  E  E     X. 

inTEEOSTOSIS. 

Under  the  liead  of  diffused  hyperostosis  it  will  be  con- 
venient to  group  together  those  remarkable  examples  of 
hypertrophy  of  the  maxillte,  and  more  or  less  of  other  bones 
of  the  face  and  cranium,  which  have  occurred  from  time  to 
time,  and  have  been  recorded  b}'-  Howship,  Grliber,  Astley 
Cooper,  Lickersteth,  and  others.  0.  Weber  regards  the  dis- 
ease as  the  result  of  erysipelas,  and  compares  it,  in  its  results, 
to  elephantiasis  of  the  soft  structures  ;  while  Virchow  has 
given  it  tlie  name  of  "  leontiasis  ossea." 

Mr.  Howship's  case  is  recorded  in  that  gentleman's 
"  Practical  Observations  in  Surgery"  (1816).  The  patient, 
when  al)out  forty-five  years  of  age,  and  apparently  in  per- 
fect health,  was  exposed  to  a  cold  wind,  immediately  after 
which  he  perceived  an  itching  and  heat  in  liis  eyes,  and 
swelling  of  tlie  face  rapidly  supervened.  A  small  tumour 
formed  just  below  the  inner  angle  of  each  eye,  which  burst, 
and,  after  twelve  weeks,  he  was  able  to  resume  his  employ- 
ment. He  suffered  from  inflammatory  attacks  in  the 
tumours,  with  much  pain  in  the  head,  on  more  than  one 
occasion,  and  consulted  many  medical  men,  but  no  treat- 
ment relieved  the  disease  or  retarded  the  growth  of  the 
tumours,  which  increased  slowly,  and  were  of  stony  hard- 
ness. The  eyes  were  projected  from  the  orbits  by  the 
tumours,  and  the  riglit  eye  inflamed  and  burst,  while  the 
left  was  accidentally  ruptured  by  a  blow.  The  jiatient 
lived  to  over  sixty  years  of  age,  and  died  of  apoplexy,  having 
been  occasionally  maniacal  during  the  last  two  years  of  his 
life.     The  accompanying   portrait  (fig.    54)   is   taken  from 


MR   HOWSHIPS   CASE. 


143 


Mr.  Howsliip's  work.  The  skull  of  this  patient  is  preserved 
in  the  College  of  Surgeons  (1606),  and  shows,  as  might 
be  anticipated  from  the  portrait,  two  large  masses  of  almost 
exactly  symmetrical  form  and  arrangement,  which  have 
partially  coalesced  in  the  median  line.  The  growths  are 
as  hard  as  ivory,  and  consist  of  a  very  close  cancellous 
structure.  They  project  more  than  three  inches  in  front 
of  the  face,  and  an  inch  beyond  the  malar  bones  on  each 

Fig.  54. 


side ;  they  completely  fill  both  orbits,  the  cavities  of  the 
nose,  and,  probably,  both  antra,  and  they  extend  as  far 
backwards  as  the  pterygoid  plates  of  the  sphenoid  bone.  In 
the  Catalogue  of  the  Museum  it  is  stated  that  the  man 
attributed  the  growths  to  repeated  blows  received  on  the 
face  in  fighting,  but  Mr.  Howship  makes  no  mention  of 
this,  and  the  information  was  probably  derived  from  Mr. 
Langstaff,  in  whose  collection  the  preparation  originally 
was. 

A  skull  of  a  Peruvian^  also  in  the  Museum  of  the  College 
of  Surgeons  (1238),  exhibits  the  same  form  of  disease,  but 
of  a  more  diffused  character,  all  the  bones  of  the  face,  as 
well  as  the  frontal  and  the  adjacent  parts  of  the  sphenoidal 
and  parietal  bones,  being  enlarged  and  thickened  in  a  re- 


144  HYPEROSTOSIS    OF    THE   JAWS. 

markable  manner.  The  nasal  fossre  and  orbits  are  nearly 
closed,  the  superior  maxillary  bones,  and  the  orbital  portions 
of  the  malar  and  frontal  bones,  having  grown  into  great 
knobbed  and  tubercular  masses,  in  which  their  original  form 
can  be  hardly  discerned.  The  hard  palate  is  similarly 
diseased.  The  lower  jaw  is  enormously  enlarged  at  its 
right  angle,  and  in  the  greater  part  of  its  right  half  it 
measures  upwards  of  five  inches  in  circumference,  and  all 
but  three  of  its  alveoli  are  closed  up.  A  section  of  the 
lower  jaw  shows  that  its  interior  is  composed  of  an  almost 
uniformly  hard  and  compact,  but  finely  porous,  bone.  There 
is  no  history  attached  to  the  specimen. 

Sir  Astley  Cooper's  patient  was  a  Billingsgate  fish-woman, 
long  remarkable  for  her  hideous  appearance,  who  died  of 
apoplexy  in  St.  Thomas's  Hospital,  in  tlie  museum  of  which 
institution  the  skull  is  preserved.  (C.  195.)"  In  connexion 
with  each  superior  maxilla  is  a  rounded  bony  growth,  ex- 
tending from  the  lower  margin  of  the  orbit  to  the  roots 
of  the  alveolar  processes.  The  cavity  of  each  antrum  is 
occupied  by  the  growth,  whicli  by  its  projection  has  en- 
croached upon  the  nasal  fossa\  and  iilled  the  frontal  and 
ethmoidal  sinuses.  The  case,  therefore,  closely  resembles 
Mr.  Howship's  specimen. 

Mr.  Bickersteth's  very  remarkaljle  specimen  was  exhi- 
bited to  the  Pathological  Society  of  London  in  April,  1866, 
by  Dr.  Murchison,  and  its  description  in  the  Society's  Trans- 
actions is  illustrated  with  admirable  lithographic  drawings. 

The  patient,  who  died  at  the  age  of  thirty-four,  first 
noticed  an  enlargement  of  the  bones  of  the  face  when  a  boy 
of  fourteen.  The  swelling  of  the  face  gradually  increased, 
and  thirteen  years  after  its  commencement  a  similar  hard 
swelling  appeared  along  the  course  of  the  left  fibula.  About 
two  years  before  death  lie  began  to  suffer  severe  pain,  which 
continued  to  his  death,  this  being  the  result  of  emaciation, 
consequent  upon  the  encroachment  of  the  disease  upon  the 
mouth.  All  the  bones  of  the  head  are  more  or  less  involved 
in  the  disease,  with  the  remarkable  exception  of  the  occipital 
bone.     The  malar  bones  are  developed  into  dense  globular 


bickersteth's  case.  145 

masses,  the  size  of  an  orange.  The  palatal  processes  of  the 
superior  maxilhe  are  also  greatly  diseased,  a  rounded  mass 
projecting  down  on  each  side  so  as  to  fill  up  the  cavity  of 
the  hard  palate  to  a  level  with  the  alveolar  ridge.  The 
lower  jaw  is  enormously  thickened  in  every  direction,  the 
right  side  more  so  than  the  left.  Little  trace  can  be  'Seen 
of  a  condyle,  coronoid  process,  or  sigmoid  notch,  the  whole 
being  fused  into  one  uniform  globular  mass. 

A  very  elaborate  account  of  the  specimen,  with  measure- 
ments and  microscopical  appearances  by  Mr.  De  Morgan, 
will  be  found  in  the  17th  vol.  of  the  Pathological  Society's 
Transactions,  from  which  the  above  is  condensed. 

A  fourth  specimen  is '  preserved  in  the  Musee  Duj)uy- 
tren,  in  which  both  upper  and  lower  jaws  are  extensively 
affected,  and  specimens  showing  the  disease  in  a  lesser  degree 
will  be  found  in  the  museum  of  the  Dental  Hospital, 
Leicester  Square,  and  elsewhere. 

In  all  these  specimens  the  external  surface  of  the  bones 
affected  is  more  or  less  coarsely  tuberculated ;  the  tissue  is 
hard  and  dense,  and  minutely  perforated  for  the  passage  of 
bloodvessels.  In  the  case  of  the  lower  jaw  of  the  Peruvian 
skull,  the  interior  is  composed  of  an  almost  uniformly  hard 
and  compact,  but  finely  porous  bone.  Traces  of  the  original 
walls  of  the  jaw  are  discernible  nearly  an  inch  beneath  the 
surface  of  the  most  enlarged  part,  but  its  interior  is  filled  up 
with  the  same  kind  of  osseous  substance  as  that  which  is 
outside  the  trace  of  the  wall. 

A  microscopical  examination  of  the  St.  Thomas's  Hospital 
specimen  "  shows  it  to  consist  of  two  kinds  of  bony  matter  ; 
one  firm  and  compact,  while  the  other  is  more  or  less  soft 
and  spongy.  In  the  former,  Haversian  canals  occur,  having 
concentric  laminpe  around  them,  but  in  the  spongy  portion 
cancelli  only  are  present,  and  the  bone  exhibits  a  granular 
structure,  with  numerous  bony  cells  arranged  in  no  definite 
order." 

In  Mr.  Bickersteth's  specimen,  "  The  compact  structure 
is  traversed  in  every  direction  by  large  branching  and  com- 
municating vascular  canals,  forming  in  some  places  a  close 

L 


146  HYPEKOSTOSIS    OF    THE    JAWS. 

network The  sj)aces  between  the  canals  are    filled 

up  by  bone-tissue  of  ordinary  character.  The  lacuna)  are  in 
general  very  numerous,  but  they  are  small,  and  for  the  most 
part  elongated.  Very  few  traces  of  true  Haversian  systems 
are  to  be  seen." 

It  is  stated  in  the  report  upon  the  last  specimen,  that  the 
microscopical  appearances  are  nearly  identical  with  those  of 
the  Peruvian  skull  in  the  Hunterian  Museum. 

The  disease  appears  to  consist  primarily  in  some  inliam- 
matory  affection  of  the  periosteum,  which  leads  to  the  de- 
posit of  new  bone,  and  tlie  expansion  and  filling  up  of  the 
original  osseous  structure.  It  appears  to  be  entirely  un- 
connected with  syphilis  or  struma,  and  to  be  completely 
beyond  the  control  of  remedies,  though  the  continued  ex- 
hibition of  iodine  (a  drug  unknown  when  these  cases  were 
in  their  early  stage)  might  possibly  be  of  benefit.  The 
resemblance  these  cases  bear  to  one  another  is  very  remark- 
able, and  there  was,  a  few  years  back,  an  attendant  at 
Somerset  House  who  miglit  have  sat  for  the  portrait  of  Mr. 
Howshix^'s  patient. 

In  the  Museum  of  St.  Bartholomew's  Hospital  is  a 
specimen  (I.  62),  showing  obliteration  of  the  antra,  due  to 
hypertropliy  of  the  bone,  of  the  same  character  as  in  the 
specimen  described  above,  but  in  an  earlier  stage.  When 
the  disease  affects  only  one  of  the  maxillte,  which  is  its 
favourite  seat,  operative  interference  will  be  advisable.  Mr. 
Stanley  ("  On  Diseases  of  the  Bones,"  p.  297)  gives  the  case 
of  a  girl  of  fifteen  years  in  whom  enlargement  of  the  nasal 
process  of  the  superior  maxilLe  had  been  observed  for  eight 
years,  and  was  increasing.  There  was  no  external  deformity, 
but  it  was  thought  advisable  to  interfere  at  an  early  date, 
when  it  was  found  that  obliteration  of  the  antrum  had 
already  taken  place,  as  in  the  preceding  case.  The  entire  jaw 
was  removed,  but  the  patient  unfortunately  died  of  erysipelas. 

In  tlie  Museum  of  King's  College  is  another  specimen 
(1201),  which  shows  well  the  obliteration  of  the  antrum  by 
hypertrophy  of  its  walls.  The  tumour  was  removed  in  1842, 
by  Sir  William    Fergussou,  from  a  girl  of  twelve,  in  whom 


FERGUSSON  S    CASE. 


147 


some  enlargement  of  the  face  had  been  noticed  from  the  age 
of  four,  and  whose  portrait  is  shown  in  fig.  55,  taken,  by 
permission,  from  that  eminent  surgeon's  "  Practical  Surgery." 
The  patient  made  a  perfect  recovery,  and  the  particulars  of 
the  case  will  be  found  in  The  Lancet  of  February  and 
March,  1842.  Fig.  56  shows  her  portrait  after  recovery 
from  the  operation. 


Fig.  55. 


Fig.  56. 


In  the  same  museum  is  a  specimen  of  the  disease  in  the 
ramus  of  the  lower  jaw,  removed  by  the  same  surgeon  from 
a  girl  of  thii'teen,  by  sawing  in  front  of  the  molar  teeth  and 
disarticulating.      The  patient  made  a  good  recovery. 

I  liave  now  met  with  several  cases  more  or  less  closely 
resembling  those  described  above.  The  most  marked  one 
was  in  a  lady,  aged  thirty-nine,  who  had  a  blow  on  the  right 
cheek  when  fourteen,  and  noticed  an  outgrowth  when  about 
eighteen.  When  she  was  brought  to  me  by  Mr.  Salzmann, 
of  Brighton,  I  found  a  very  marked  projection  of  the  right 
cheek,  due  to  an  enlargement  of  the  superior  maxilla,  which 
was  smooth  and  uniform  on  its  surface.  Without  any  external 

L2 


148  HYPEROSTOSIS    OF    THE    JAWS. 

incision  I  succeeded  in  gouging  away  a  quantity  of  dense 
bone  without  opening  any  antral  cavity,  and  thus  reduced 
the  face  to  a  symmetrical  appearance.  The  cure  has,  I 
believe,  been  permanent. 

Lesser  degrees  of  enlargement  of  both  upper  and  lower  jaws 
of  the  same  kind  are  not  very  uncommon,  and  in  one  or  two 
patients  I  have  certainly  seen  good  follow  the  prolonged 
administration  of  the  syrup  of  iodide  of  iron.  In  the  31st  vol. 
of  the  Pathological  Society  s  Transactions,  Mr.  E.  W.  Parker 
gives  a  drawing  of  remarkable  symmetrical  hyperostoses  of 
the  angles  of  the  lower  jaw  in  a  girl  of  twelve,  which  he 
considers  to  be  the  result  of  congenital  syphilis,  and  the 
subsequent  history  confirmed  the  diagnosis,  the  gummata 
disappearing  under  treatment.  I  have,  however,  twice  been 
consulted  for  precisely  similar  hypertrophy  of  the  angles  of 
the  jaws  occurring  in  perfectly  healthy  young  women,  one 
being  the  daughter  of  a  medical  friend,  in  whom  there  was  no 
suspicion  of  congenital  taint. 

The  cases  of  "  Osteitis  deformans"  described  by  Sir  James 
Paget  {Mcdico-Ghirurgiccd  Transactions,  li.)  do  not  come 
into  the  same  category  as  the  cases  given  above,  for  though 
the  cranium  is  often  affected,  the  facial  bones  have  a 
singular  immunity  from  that  disease.  In  several  of  these 
cases  also  there  was  found  cancer  in  some  part  of  the  body. 
But  that  cancer  may  co-exist  with  hyperostosis  of  the  jaw 
bones  is  shown  by  a  case  recorded  by  Dr.  Cayley  {PatJwlo- 
gical  Society's  Trans.,  xxix.),  where  cancer  of  the  lung  was 
found  together  with  hyperostosis  of  the  lower  jaw,  which 
presented  the  following  appearances  : — "  The  lower  jaw  was 
uniformly  enlarged  and  the  alveolar  border  projected  beyond 
that  of  the  upper  one,  with  which  it  could  not  be  brought 
into  apposition.  All  the  molar  and  pre-molar  teeth  were 
wanting,  and  the  sockets  of  the  molar  teeth,  except  that  for 
the  first  riglit  and  the  last  left  one,  were  filled  up  with  bone, 
the  socket  of  the  first  right  molar  was  much  enlarged  and 
would  admit  the  tip  of  the  little  finger ;  it  was  continuous 
with  the  socket  for  the  adjacent  bicuspid,  which  had  itself 
ulcerated  through   tlie   anterior  surface  of  the  jaw.      The 


author's  casr.  149 

alveolar  border  of  the  bone  was  greatly  expanded,  especially 
in  the  molar  regions,  where  it  measured  in  depth  two  inches 
and  a  half.  The  rest  of  the  bone  was  also  greatly  increased 
in  thickness,  the  groove  and  forame]i  for  the  inferior  dental 
vessels  and  nerve  were  remarkably  deep  and  wide.  The 
condyle  on  each  side  had  a  short  thick  neck,  and  the  sigmoid 
notch  was  wider  and  less  deep  than  usual.  The  angle  was 
very  obtuse^  as  in  edentulous  jaws. 

Fig.  51. 


A  remarkable  case  of  hyperostosis  with  hypertrophy  of 
the  tissues  of  the  corresponding  side  of  the  face  has  been 
under  my  notice  for  fourteen  years.  The  patient,  a 
healthy  boy,  aged  twelve,  was  sent  to  me  in  November,  1869, 
by  Mr,  Giles,  of  Staunton-on-Wye,  under  whose  care  he 
had  been  from  birth.  When  three  months  old  the  patient's 
face  was  noticed  to  be  enlarged  on  the  left  side,  and  this 
enlargement  gradually  increased  until  he  presented  the  ap- 
j)earance  shown  in  fig.  57,  from  a  photograph  taken  in 
1869.  The  left  superior  maxilla  had  shared  in  the  hyper- 
trophy, and  the  condition  of  the  palate  and  teeth  is  shown 
in  fig.  58^  reduced  from  a  cast,  where  it  will  be  seen  that 


150 


HYPEROSTOSIS   OF   THE  JAWS. 


the  temporary  incisors  and  canine  teetli  are  still  in  situ  on 
the  diseased  side,  though  they  have  been  replaced  by  the 
permanent  teeth  on  the  healthy  side.  I  removed  the  left 
superior  maxilla  on  December  1,  1869,  in  the  hope  that  the 
removal  of  the  bone  and  the  necessary  incisions  in  the  cheek 
would  lead  to  a  permanent  relief  of  the  deformity.  The 
patient  made  a  perfectly  good  recovery,  and  I  subsequently 
endeavoured  to  open  the  eye  and  to  destroy  a  portion  of  the 
tissue  of  the  cheek,  but  without  much  permanent  success, 
the  jDatient's  condition  two  years  after  the  operation  being 
as  unsightly  as  before.  I  liave  recently  (1883)  received  from 
Mr.  Giles  photographs  of  this  patient,  which  show  that  the 
hypertrophy  of  the  soft  parts  has  kept  pace  with  the  patient's 
growth. 

Fig.  5S.  Fig.  59. 


A  section  of  the  removed  upper  jaw  showed  considerable 
condensation  of  the  bone,  and  the  fact  that  the  permanent 
incisors  and  canine  teeth,  together  with  the  uncut  molars, 
were  imbedded  in  the  bone,  and  holding  very  much  their 
natural  relations  to  the  temporary  teeth  (fig.  59).  Mr. 
Charles  Tomes,  who  kindly  examined  the  specimen  micro- 
scopically, reported  that  "  the  structure  is  remarkable  on 
account  of  the  absence  of  well-developed  regular  Haversian 
systems.  The  bone  is  everywhere  excavated  by  large 
irregular  spaces,  around  which  there  is  but  little  appearance 
of  lamination,  so  that  it  presents  some  little  resemblance  to 
so-called  '  jorimary  bone' ;  tlie  lacunai  are  ai'ranged  some- 
what irregularly.     None  of  the  peculiar  branched  vascular 


author's  case.  151 

canals,  figured  by  Mr.  De  Morgan  in  his  account  of  the 
microscopic  characters  of  Mr.  Bickersteth's  case,  were  ob- 
served in  their  sections.  That  the  whole  of  the  bone  has 
from  an  early  period  participated  in  the  morbid  action  is 
indicated  by  the  fact  that,  although  the  teeth  have  attained 
to  something  like  the  stage  of  development  appropriate  to 
the  patient's  age,  the  alveolar  border  has  not  the  development 
■of  the  jaw  in  the  antero-posterior  direction,  being  insufficient 
to  allow  of  the  second  permanent  molar  coming  down  and 
rancjin"  with  the  other  teeth.  The  second  molar  is  a  small 
tooth,  and  the  wisdom  tooth  is  greatly  stunted." 


152 


CHAPTEK  XI. 


DISEASES    OF   THE    ANTKUM. 


Before  entering  upon  the  consideration  of  the  diseases  of 
tlie  antrum,  it  will  be  convenient  to  say  a  few  words  re- 
specting the  anatomical  relations  of  that  cavity.  Known  as 
early  as  the  time  of  Galen,  but  connected  inseparably  with 
the  name  of  Highmore,  who  described  it  as  "  conical  and 
somewhat  oblong,"  and  from  whose  work  figs.  60  and  61  are 


Fig.  60. 


Fig.  61. 


taken,  the  antrum  has  been  more  or  less  correctly  described 
by  all  modern  anatomists.  Holden  compares  it  aptly 
enough  to  "  a  triangular  pyramid,  with  the  base  towards  the 
nose  and  the  apex  towards  the  malar  bone ;"  and  mentions 
the  occurrence  of  "  thin  plates  of  bone  which  are  often 
found  extending  across  the  antrum."  The  most  compre- 
hensive account,  however,  of  the  antrum  in  modern  times  is 
to  be  found  in  a  paper  by  Mr.  W.  A.  K  Cattlin,  F.K.C.S., 
in  vol.  ii.  of  the  Transactions  of  the  Odontologica.l  Society  of 
London,  and  by  the  kindness  of  that  gentleman  I  am  enabled 
to  reproduce  his  valuable  illustrations. 


ANATOMY    OF    THE    ANTRUM. 


153 


As  the  result  of  the  examination  of  a  hundred  specimens, 
Mr.  Cattlin  finds  that,  as  a  rule,  the  antrum  is  larger  in  the 
male  than  in  the  female,  and  that  it  diminishes  in  size  with 
extreme  age.  In  the  young  subject,  likewise,  the  cavity  is 
small,  and  its  walls  comparatively  tliick.     Fig.  62  shows,  in  a 

FiCx.  62. 


transverse  section,  both  the  roof  and  tloor  of  an  adult  antrum 
of  the  common  sha]3e  and  size,  capable  of  containing  two  and 
a  half  drachms  of  fluid.  Fig.  63  is  a  drawing  of  a  large  adult 
antrum  capable  of  containing  eight  drachms  of  fluid,  whilst 
fig.  64  shows  a  small  adult  antrum  containing  only  one 
drachm  of  fluid.  The  two  antra  are  often  unsymmetrical  in 
size  and  shape ;  thus  fig.  65  shows  a  much  larger  and  deeper 
cavity  on  one  side  than  on  the  other.  The  antrum  may 
even  extend  irregularly  into  the  malar  bone,  forming  a  sup- 
plementary cavity  there,  as  seen  in  fig.  66  (where  the  view 
is  taken  from  the  nasal  cavity).  The  most  remarkable  vari- 
ation, however,  is  due  to  the  development  of  the  ridges  of 
bone  already  mentioned,  which  subdivide  the  cavity ;  these 
are  very  variable  in  size  and  shape.  Fig.  67  is  an  example 
of  an  antrum  divided  by  a  thin  plate  of  bone,  and  fig.  68  of 
one  divided  by  a  thick  ridge  of  bone.  Foss^ii  of  considerable 
depth  are  often  found  in  the  floor  of  the  antrum,  par- 
ticularly at  the  anterior  and  posterior  extremities,  of  which 


154 


DISEASES   OF   THE   ANTRUM. 


fig.  69  is  a  good  example,  showing  on  one  side  a  perforation 
by  an  alveolar  abscess.     A  rare  form  is  when  fosste  or  cells 


Fig.  63. 


are  developed  beneath  the  orbital  plate  (lig.  70),  or  a  cuJ  Jr 
sac  is  formed  close  to  the  lachrymal  groove  (fig.  71). 

Tiie  i^osition  and  size  of  the  opening  between  the  antrum 
and  tlie  middle  meatus  of  tlie  nose  are  points  of  some  iui- 


ANATOMY    OF    THE    ANTRUM. 


155 


portance.     The  size  of  the  aperture  found  in  a  macerated 
superior  maxilla  gives  a  verj^  exaggerated  idea  of  the  open- 


FiG.  64. 


ing  in  the  articulated  skull,  when  it  is  encroached  upon  by 
the  palate,  inferior  turbinate, and  ethmoid  bones,\vhich  narrow 


Ftg.  65. 


156 


DISEASES    OF   THE    ANTRUM. 


and  subdivide  the  opening  into  two.     In  the  recent  subject 
these  are  covered  in  by  the  nuicous  membrane  of  the  nose. 


Fio.  GG. 


so  that  ordinarily  there  is  only  a  small  oblique  aperture  left 
in  front  of  the   unciform  process  of  the  etlimoid,  and  close 


Fig.  67. 


ANATOMY    OF   THE    ANTRUM. 


157 


behind  the  infundibuliiin.      It  should  bo  observed,  that  this 
opening  is  at  the  upper  part  of  and  not  near  the  floor  of 


Fig.  68. 


tbe  antrum,  and  that  it   opens  into  the  middle   meatus  of 
the  nose.     Occasionally  a  second  small  aperture    is   found 


Fig.  69. 


behind  this,  and  nearer  to  the  floor  of  the  sinus,  which  has 
been  always  regarded  as  a  natural  formation.      M.  Giraldes 


158 


DISEASES    OF   THE    ANTRUM. 


however,  in  liis  "  Reclierches  sur  les  Kystes  Muqueux  du 
Simis  ]\Iaxillairo"    (Paris,   1860),  maintains    that   the  pos- 


FiG.  70. 


terior  opening,  when  it  exists,  is  always  the  result  of  patho- 
logical change,  and  that  tlie  anterior  opening  is  into  the 
infundihulum,  and  not  into  the  meatus  itself.      I   believe 


SUPPURATION   IN   THE  ANTRUM.  159' 

that  slight  variations  in  the  position  of  the  opening  exist ; 
but  it  is  undoubted  that  the  aperture  is  very  minute,  and 
quite  inaccessible  from  the  nose. 

Su}ypnration  in  the  antrum,  or,  as  it  is  sometimes  termed, 
abscess,  is  ordinarily  the  result  of  inflammation  extending 
from  the  teeth  to  the  lining  membrane  of  the  cavity ;  and 
the  disease  might  therefore  be  not  incorrectly  termed  an 
empyema,  as  proposed  by  0.  Weber.  The  roots  of  the  first 
and  second  molar  teeth  often,  and  the  bicuspids  and  canine 
occasionally,  form  prominences  in  the  floor  of  the  antrum  ; 
and  when  these  teeth  become  carious,  the  thin  plate  of  bone 
covering  their  fangs  not  unfrequently  becomes  affected,  and 
disease  is  set  up  in  the  cavity.  The  fangs  of  the  first  molar 
tooth  are  occasionally  found  in  health  to  be  uncovered  by 
bone,  and  to  project  beneath  the  lining  membrane  of  the 
antrum ;  and  under  these  circumstances,  irritation  and  in- 
flammation would  be  still  more  likely  to  occur.  But  an 
abscess  may  be  formed  in  the  alveolus,  and  eventually  burst 
into  the  antrum,  though  connected  originally  with  teeth  not 
usually  in  relation  with  the  cavity.  Of  this  an  example 
will  be  found  in  the  Appendix,  in  a  case  (VII.)  given  to 
me  by  Mr.  Margetson,  of  Dewsbury,  where  the  teeth  affected 
were  the  canine  and  incisors.  This  perforation  of  an  alveolar 
abscess  is  seen  also  in  fig.  69. 

Other  causes  besides  disease  of  the  teeth  have  been  known 
to  induce  suppuration  in  the  antrum,  such  as  a  violent  blow 
on  the  face  ;  and  Dr.  Eees  has  recorded  an  example,  in  an 
infant  a  fortnight  old,  as  the  result  of  pressure  during  birth 
{Medical  Gazette,  vol.  iv.).  It  is  probable  also  that  the  dis- 
ease may  result  from  catarrhal  or  other  inflammation  of  th& 
lining  membrane ;  and  it  has  been  excited  by  the  entrance 
of  foreign  bodies  either  from  without  or  from  within  the 
mouth,  after  the  extraction  of  a  tooth  communicating  with 
the  cavity.  In  the  3rd  volume  of  the  Transactions  of  the 
Clinical  Society,  Mr.  Moore  recorded  a  case  of  abscess  in  the 
superior  maxilla,  which  he  believed  to  be  due  to  the  ingress 
of  particles  of  food  by  the  side  of  a  tooth,  though  the  facts 
might  possibly  bear  a  different  interpretation. 


IGO  DISEASES    OF   THE    ANTRUM. 

The  symptoms  uf  suppuration  in  the  antrum  are  at  first 
simply  those  of  intlammation  of  the  hning  membrane — dull, 
deep-seated  pain  shooting  up  the  face  and  to  the  forehead, 
tenderness  of  tlie  cheek,  with  some  fever  and  constitutional 
disturbance  ;  but  occasionally  the  23ain  is  most  acute,  and  of 
a  sharp,  stabbing,  neuralgic  character.  A  slight  rigor  may 
usher  in  the  formation  of  matter,  which  will  find  its  way 
into  the  nostril  when  the  patient  is  lying  on  his  sound  side, 
■either  through  the  normal  aperture  or  through  an  opening 
caused  by  absorption,  as  maintained  by  M.  Giraldes.  An 
•offensive  odour  is  now  sometimes  perceptible  to  the  patient, 
though  not  to  those  around  liim — thus  differing  markedly 
from  what  occui's  in  oziena — and  a  sudden  discharge  of 
matter  from  the  nostril  when  blowing  the  nose  may  relieve 
all  the  symptoms  for  the  moment.  The  more  common  course 
of  events  is,  however,  that  without  any  acute  pain  the  patient 
notices  that  lie  lias  a  purulent  discharge  from  the  nose 
when  blowing  it,  and  perhaps  is  aware  that,  when  lying 
down,  the  discharge  finds  its  way  into  the  throat.  Tliis 
latter  point  is  often  overlooked,  however,  though  there  may 
be  a  complaint  of  a  very  disagreeable  taste  in  the  mouth, 
and  a  tendency  to  nausea  in  the  morning,  with  a  hawking  up 
of  pellets  of  inspissated  pus. 

With  all  this  there  is  no  distension  of  the  antrum,  and  it 
is  tliis  fact  which  frequently  misleads  the  practitioner.  It  is 
certain,  however,  that  in  health  there  is  invariably  an 
opening  between  the  antrum  and  the  nostril,  and  that,  even 
wlien  tliis  is  closed,  the  wall  is  very  thin  and  readily  ab- 
sorbed, and  it  is  quite  exceptional,  therefore,  when  tlie 
antrum  is  so  distended  with  pus  as  to  give  rise  to  any 
prominence  of  the  cheek.  Undoubtedly  cases  of  this  kind 
liave  been  recorded,  but  it  may  Ije  doubted  wdiether  some 
of  them  were  not  examples  of  cyst,  the  contents  of  which 
had  become  purulent,  for  we  know  tliat  cysts  in  the  wall 
of  the  antrum  readily  produce  great  deformity.  The 
natural  opening  into  llie  nose  is  not  at  tlie  level  of  the 
bottom  of  the  cavity  of  the  antrum,  and  hence  there  is 
always   a   small    residuum   of  discharge,    which  the  patient 


SUPPURATION    IN    THE    ANTRUM.  161 

can  only  partially   get   rid   of  by  holding   the   liead  on  one 
side. 

Given,  a  patient  who  complains  of  purulent  discharge 
from  the  nostril,  with  occasionally  a  disagreeable  smell,  and 
the  case  is  too  apt  to  be  put  down  as  one  of  ozsena,  and 
treated  by  nasal  douches,  snuffe,  &c.  But,  as  already  men- 
tioned, the  offensive  smell  is  perceived  only  by  the  patient, 
and  not  by  his  friends,  the  reverse  being  the  case  in  ozsena ; 
and,  again,  the  discharge  is  only  occasional,  is  determined 
by  the  position  of  the  head,  and  is  simply  purulent,  whereas 
in  oza3na  the  discharge  is  constant,  and  mixed  with  offensive 
crusts  from  the  nasal  cavities.  Again,  the  dull  ache,  varied 
occasionally  by  acute  pain,  is  apt  to  be  referred  to  the  teeth 
alone,  and  the  most  careful  examination  may  fail  to  detect 
any  special  tenderness  in  any  one  tooth.  Hence,  after  ex- 
hausting the  usual  routine  remedies  for  neuralgia,  I  have 
known  wholesale  extraction  of  useful  teeth  undertaken  with 
no  benefit,  unless  it  should  fortunately  happen  that  the 
tooth  which  has  perforated  the  antrum  should  be  extracted 
early,  when  the  discharge  of  pus  at  once  clears  up  the  nature 
of  the  case. 

The  more  ordinary  consequence,  however,  of  an  unrecog- 
nised empyema  of  the  antrum  is  the  damage  done  to  the 
digestive  organs,  by  the  constant  swallowing  of  purulent 
fluid  during  sleep.  Under  these  circumstances,  the  patient 
is  always  ailing,  is  unable  to  take  food  in  the  morning,  and 
may  be  reduced  to  a  state  of  great  prostration,  even  danger- 
ous to  life.  The  usual  remedies  for  indigestion  are  likely  to 
be  of  little  service  so  long  as  the  purulent  drain  continues. 

In  exceptional  cases  the  pus,  not  finding  an  exit,  distends 
the  antrum,  causing  partial  absorption  of  the  walls,  and  thus 
both  bulging  out  the  cheek  and  thrusting  up  the  floor  of 
the  orbit.  Fig.  72  shows  the  prominence  of  the  cheek  thus 
produced  in  a  patient  under  the  care  of  Sir  William 
Fergusson.  Under  these  circumstances  the  affection  is 
readily  recognised  by  the  peculiar  crackling  which  is  per- 
ceived when  the  thinned  bone  is  pressed  upon,  and  the 
matter,  if  not  evacuated,  will  shortly  find  a  way  out  for 

M 


162 


DISEASES    OF   THE    ANTRUM. 


itself,  either  by  the  side  of  the  teeth,  throiigli  the  front  wall 
of  the  antrum,  or  through  the  floor  of  the  orbit ;  in  either 
of  which  cases  considerable  necrosis  and  ultimate  scar  are 
likely  to  be  the  consequences. 

The  possibility  of  both  antra  being  affected  either  simul- 
taneously or  consecutively,  must  not  be  overlooked.  I  have 
a  patient  now  under  my  care  whose  right  antrum  I  emptied 

Fig.  72. 


some  years  back,  and  who  lias  now  symptoms  which  point 
to  the  presence  of  matter  in  the  opposite  antrum,  and  Mr. 
C.  Tomes  has  met  with  the  same  occurrence. 

Tlie  elevation  of  the  floor  of  the  orbit  already  described 
may  sim]jly  displace  the  eyeball  and  render  it  temporarily 
blind,  as  in  a  case  recorded  by  Mr.  J.  Smith,  of  Leeds, 
{Lancet,  Feb.  14,  1857),  or  it  may  lead  to  permanent  amau- 
rosis— a  point  to  which  Mr.  Salter  called  especial  attention 
in  the  Medico-Chirurgical  Transactions  for  1862.  Mr. 
Salter's  patient,  a  young  woman,  twenty-four  years  of  age, 
was  attacked  M'ith  violent  toothache  in  the  first  right  upper 


AMAUROSIS    FROM    ANTRAL    DISEASE.  K))) 

molar,  which  was  followed  by  enormous  swelling  of  tlie  side 
of  the  face  and  intense  pain.  The  eyeljall  tlien  Ijecame 
protruded,  and  she  soon  after  perceived  that  tlie  eye  was 
blind.  Shortly  after  the  establishment  of  these  symptoms, 
"  abscess"  of  tlie  antrum  pointed  at  the  inner  and  then  at 
the  outer  canthus,  and  a  large  discharge  of  pus  at  both 
orifices  followed  ;  these  orifices  soon  closed,  but  the  general 
symptoms  of  the  part  continued  unchanged — the  swelling  of 
the  face,  protrusion  of  the  globe,  and  blindness.  This  state 
of  things  lasted  for  about  three  weeks,  when  the  patient  was 
sent  to  Guy's  Hospital,  and  admitted.  At  this  time  the 
patient  exhibited  hideous  disfigurement  from  swelling  of  the 
face,  cedema  of  the  lids,  and  lividity  of  the  surrounding 
integument.  Upon  examining  the  mouth,  it  was  found  that 
the  carious  remains  of  the  first  right  upper  molar  appeared 
to  be  associated  with,  and  to  have  caused  the  disease. 
Together  with  the  other  contiguous  carious  teeth,  this  was 
removed,  and  led  by  an  absorbed  opening  into  the  floor  of 
the  antrum.  The  haemorrhage  which  followed  the  operation 
was  discharged  partly  through  the  nose,  and  partly  through 
the  orifices  in  the  cheek,  as  well  as  from  the  tooth-socket, 
showing  a  common  association  of  these  openings  with  the 
antrum.  The  condition  of  the  eye  constituted  the  most  im- 
portant symptom,  and  the  most  distressing.  The  sight  was 
utterly  gone  ;  the  globe  prominent  and  everted.  There  was 
general  deep-seated  inflammation  of  the  fibrous  textures  of 
the  eye.  The  pupil  was  large  and  rigidly  fixed ;  it  did  not 
move  co-ordinately  with  the  other  under  any  circumstances. 
Some  abatement  of  the  symptoms  followed  the  extraction  of 
the  tooth  ;  but  it  was  soon  found  that  there  was  a  consider- 
able sequestrum  of  dead  bone,  which  was  removed.  The 
necrosis  involved  the  front  part  of  the  floor  of  the  orbit, 
the  cheek  surface  of  the  superior  maxilla,  with  the  infra- 
orbital foramen,  and  a  large  plate  of  bone  from  the  inner 
(nasal)  wall  of  the  antrum.  The  removal  of  the  dead  bone  was 
followed  by  the  immediate  and  complete  cessation  of  all  in- 
flammatory symptoms  ;  but  the  eye  remained  sightless,  and 
the  pupil  rigidly  fixed.     About  five  weeks  after  the  removal 

M  2 


164  DISEASES    OF   THE    ANTRUM. 

of  the  dead  bone,  it  was  noticed  that  the  pupil  of  the 
affected  eye  moved  with  that  of  the  other,  under  the 
influence  of  light,  though  vision  in  it  had  not  returned.  Mr. 
Charles  Gaine,  of  Bath,  has  recorded  {British  Medical  Journal, 
Dec.  30,  1865)  a  very  similar  instance  in  a  young  woman 
of  twenty-two.  In  Mr.  Salter's  paper  will  be  found  the 
case  of  a  gentleman,  aged  thirty-five,  under  the  care  of  Mr. 
Pollock,  who  had  amaurosis  following  inflammation  without 
abscess,  and  one  by  Dr.  Briick,  where  amaurosis  followed 
abscess,  in  the  person  of  a  man  of  forty-five.  Sir  Thomas 
Watson,  in  his  "  Lectures  on  Physic,"  alludes  also  to  two 
cases  of  temporary  amaurosis,  the  result  of  diseased  teeth  in 
the  upper  jaw. 

But  even  more  serious  results  have  followed  neglected 
suppuration  in  the  antrum,  for  Dr.  Mair,  of  Madras,  has 
recorded,  in  the  Ediiiburgh  Medical  Journal  for  1866,  the 
case  of  a  gentleman  in  whom  suppuration  in  the  antrum  was 
followed  by  death  in  sixteen  days,  from  suppuration  within 
the  cranium  accompanied  by  epileptic  convulsions.  The 
full  details  of  the  case,  with  the  most  interesting  post-mortem 
appearances,  will  be  found  in  the  Appendix  (Case  VIIL). 

The  treatment  of  suppuration  of  tlie  antrum  consists,  in 
the  first  place,  in  the  extraction  of  all  decayed  teeth  or 
stumps  in  the  affected  jaw,  and  with  this  object  in  view 
those  teeth  which  are  apparently  sound  should  be  tested  by 
a  sharp  knock  with  some  metal  instrument,  when,  if  tender, 
they  should  be  extracted.  If  the  cause  of  the  mischief  is 
removed  in  time,  the  inflammation  will  subside  under  fomen- 
tation and  the  application  of  a  leech  to  the  gum ;  but  if 
matter  has  formed  it  must  be  evacuated  without  delay.  If 
the  extraction  of  a  tooth  is  followed  by  the  flow  of  pus,  the 
enlargement  of  the  aperture  in  the  socket  by  the  introduc- 
tion of  a  trocar  is  at  once  the  readiest  and  simplest  mode  of 
evacuating  the  matter ;  but  if  all  the  teeth  are  apparently 
sound,  it  will  be  advisable  to  perforate  the  alveolus  above 
the  gum  with  a  trocar,  gimlet,  or  strong  pair  of  scissors,  and 
similar  treatment  would  be  required  in  the  rare  case  of  suj^pu- 
ration  occurring  after  loss  of  the  teeth  in  old  people.     If  it  is 


TREATMENT  OF  SUPPURATION.        1G5 

determined  to  sacrifice  a  tooth  the  first  molar  is  to  he  pre- 
ferred for  extraction,  both  on  account  of  the  depth  of  its 
socket  and  also  l:)ecause,  as  mentioned  by  Salter,  it  is  more 
liable  to  decay  than  the  other  teeth.  In  puncturing  through 
the  socket  of  a  tooth  with  a  trocar  it  is  well  to  gauge  the 
depth  to  which  the  instrument  may  safely  go  with  the 
fingers  of  the  hand  which  grasps  it,  lest  injury  should  be 
unwittingly  inflicted  on  the  orbital  plate  by  the  trocar 
entering  unexpectedly,  or  a  trocar  with  a  stop  may  be  em- 
ployed if  preferred. 

After  considerable  experience  of  both  methods  I  prefer 
the  puncture  above  the  alveolus,  except  when  a  tooth 
obviously  requires  extraction,  because  I  find  that  the  aper- 
ture is  less  liable  to  close  up  than  when  made  through  the 
alveolus,  and  because  food  is  less  likely  to  find  its  way  into 
the  antrum.  It  is  necessary,  however,  not  to  direct  the 
trocar  quite  horizontally  but  a  little  upwards,  lest  in  a  case 
of  highly  arched  palate  the  floor  of  the  antrum  should  be 
injured,  as  I  have  known  on  one  occasion,  but  then  fortu- 
nately with  no  permanent  damage,  except  the  exfoliation 
of  a  minute  portion  of  the  palate. 

Whatever  method  may  be  adopted  for  emptying  the  an- 
trum, it  is  important  that  the  cavity  should  be  thoroughly 
cleansed  by  the  forcible  injection  of  warm  water  until  it 
runs  freely  from  the  nostril.  Eor  this  purpose  an  ordinary 
glass  syringe  is  quite  insufiicient,  but  I  have  satisfactorily 
employed  an  ordinary  Eustachian  catheter  for  the  purpose, 
to  which  an  india-rubber  injecting-bottle  is  adapted.  After 
a  time,  and  with  a  little  instruction,  patients  can  learn  to 
dispense  with  the  syringe  by  forcing  a  mouthful  of  water 
through  the  antrum  by  the  action  of  the  buccinator  muscles. 
After  thoroughly  cleansing,  some  detergent  and  slightly 
astringent  lotion  should  be  injected,  to  restore  the  healthy 
condition  of  the  mucous  membrane,  and  for  this  purpose 
weak  solutions  of  permanganate  of  potash  or  sulphate  of  zinc 
answer  admirably ;  but  these  cases  are  exceedingly  tedious, 
as  a  rule,  and  take  many  months  for  their  cure.  If  the 
perforation  has  been  made  through  the  socket  of  a  tooth, 


166  DISEASES    OF  THE   ANTRUM. 

care  umst  be  taken  that  particles  of  food  do  not  gain  admis- 
sion to  the  antrum,  and  this  may  be  accomplished  by  plug- 
ging the  hole  with  cotton  wool,  or,  as  suggested  by  Salter, 
by  fitting  a  metal  plate  to  the  mouth  with  a  small  tube  to 
fill  the  ajDerture,  which  can  be  corked  at  pleasure,  and  will 
serve  as  a  pipe  for  injection. 

Ordinarily  the  pus  is  readily  evacuated  through  the  nostril, 
but  I  have  seen  large  masses  of  offensive  inspissated  j)us  block 
up  the  opening  into  the  nose  and  require  very  forcible  and 
repeated  syringing  for  their  removal,  and  the  same  thing 
applies  to  clots  of  blood,  which  occasionally  give  trouble.  A 
still  more  serious  event  is  when  a  mass  of  inspissated  pus 
gives  rise  to  symptoms  closely  resembling  those  of  a  tumour 
of  the  upper  jaw  and  without  producing  that  absorption 
which  gives  rise  to  the  crackling  characteristic  of  the  presence 
of  fluid.  The  following  case  of  this  kind  occurred"  in  my 
own  practice,  and  Mr.  Mason  published  a  very  similar  one. 
A  \Aoman,  aged  forty-three,  was  admitted  under  my  care, 
complaining  of  ])aiu  and  swelling  of  the  left  side  of  the  face. 
There  M-as  an  iU- defined  swelling  over  the  region  of  the  left 
upper  jaw,  and  the  angle  of  the  mouth  on  that  side  was 
drawn  downwards.  The  swelling  was  both  hard  and  tender  ; 
the  skin  over  it  appeared  unaffected.  In  tlie  mouth  there 
was  a  tense,  elastic,  and  tender  swelling  over  the  left  half  of 
the  hard  i)alate,  displacing  the  alveolar  process  downwards. 
Slight  discharge  oozed  from  a  small  opening  in  the  mucous 
membrane  opposite  the  last  upper  molar  tooth,  the  swelling 
being  softer  about  this  spot  than  elsewhere.  The  left  nostril 
was  blocked,  its  external  wall  being  pushed  inwards,  and  the 
patient  complained  of  some  discliarge  from  it.  The  neigh- 
bouring lymphatic  glands  were  not  enlarged,  and  with  the 
exception  of  occasional  pain  in  the  tumour  the  patient 
suffered  no  inconvenience,  her  general  health  being  excellent. 
She  had  noticed  the  swelling  for  about  two  years,  and 
its  commencement  was  attributed  to  exposure  to  cold.  At 
times  the  swelling  increased,  and  became  more  troublesome, 
especially  after  })rolonged  overwork.  No  liistory  of  syphilis 
could  be  obtained,  and  her  family  liistory  Mas  good. 


CHRONIC    ABSCESS    OF    ANTRUM.  167 

Believing  that  I  had  to  deal  with  a  solid  tumour  of  the 
jaw,  I  made  an  incision  through  tlie  upper  lip  in  the  median 
line,  prolonging  it  into  the  nostril  of  the  affected  side.  The 
alveolus  and  hard  palate  having  been  divided  with  saw  and 
bone  forceps,  a  way  was  made  into  the  latter,  and  a  pul- 
taceous  offensive  mass,  about  the  size  of  a  hen's  egg,  was 
turned  out  with  the  finger.  On  microscopical  examination 
this  was  found  to  consist  of  fatty  debris,  granular  pus  cells, 
and  acicular  crystals.  As  the  larger  portion  of  the  left  half 
of  the  hard  palate  was  partially  loosened  and  absorbed  it 
was  removed  with  the  forceps.  The  cavity  of  the  wound 
was  stuffed  with  a  strip  of  lint,  aud  the  patient  made  an 
uninterruptedly  good  recovery. 

The  possible  subdivision  of  the  floor  of  the  antrum  by  bony 
septa,  already  described,'  must  be  borne  in  mind  in  operating 
upon  this  cavity,  and  especially  if  there  is  reason  to  suspect 
the  presence  of  any  foreign  body  which  may  be  keeping  up 
irritation.  In  his  paper  already  referred  to,  Mr.  Cattlin 
narrates  the  case  of  the  fang  of  a  tooth  lodging  in  one  of 
these  subdivisions,  from  which  it  was  extracted  with  difficulty. 

Suppuration  in  the  antrum  may  assume  a  more  chronic 
form  than  that  above  described,  and  from  the  slow  expansion 
of  the  jaw  which  results  may  be  mistaken  for  a  solid  growth. 
Weber  describes  a  form  of  chronic  subperiosteal  abscess  pro- 
ceeding from  a  tooth,  which  is  surrounded  by  an  osseous 
plate  or  shell  formed  from  the  periosteum,  while  it  is  sepa- 
rated from  the  antrum  by  the  maxillary  wall  itself ;  and 
believes  that  the  occurrence  of  suppuration  commencing  in 
the  bone,  either  from  this  cause  or  from  the  suppuration  of 
a  dentigerous  cyst,  is  much  more  common  than  in  the  antrum 
itself,  but  in  this  I  do  not  agree,  though  recognizing  the 
occasional  occurrence  of  the  form  of  abscess  described.  The 
diagnosis  of  these  several  forms  of  abscess  is  by  no  means 
easy,  and  errors  have  been  made  by  excellent  surgeons  in 
mistaking  them  for  solid  growths :  thus,  Liston  mentions 
("Practical  Surgery,"  p.  303)  having  seen  a  surgeon 
have  his  hands  covered  with  purulent  matter  in  attempting 
to  remove  a  supposed  tumour  of  the  jaw.     This  is  more 


108  DISEASES   OF   THE   ANTRUM. 

especially  likely  to  happen  when,  as  is  sometimes  the  case, 
considerable  hypertrophy  of  the  osseous  wall  has  taken 
place  in  consequence  of  the  irritation  the  bone  has  been 
subjected  to.  Stanley  (p.  285)  mentions  a  case  of  the  kind 
which  occurred  in  the  practice  of  Sir  W.  Lawrence  : — "  A 
woman,  aged  twenty-four,  was  admitted  with  a  large,  hard, 
round  swelling  of  the  cheek  in  the  situation  of  the  antrum  ; 
it  was  free  from  pain,  and  the  soft  parts  covering  it  were 
healthy ;  such  was  the  solidity  and  hardness  of  the  swelling 
that  it  was  supposed  that  it  might  be  an  osseous  growth  from 
the  antrum,  and  the  history  appeared  to  confirm  this  view  of 
its  nature,  as  the  woman  stated  that  about  five  months 
previously  she  had  received  a  blow  on  the  cheek,  and  that 
soon  afterwards  the  swelling  commenced,  and  had  slowly 
increased  to  its  present  magnitude,  which  .was  about  that  of 
a  midd]e-sized  orange.  A  scalpel  was  thrust  into  the  tumour 
immediately  above  the  sockets  of  the  molar  teeth,  and  healthy 
pus  flowed  from  the  opening ;  the  discharge  continued  in 
gradually  decreasing  quantity,  and  the  swelling  subsided  as 
the  walls  of  the  antrum  receded  to  their  natural  limits." 

This  thickening  of  the  bone  may  remain  permanently, 
long  after  the  cure  of  the  abscess,  and  may  necessitate  ope- 
rative interference  :  thus,  in  1850,  Sir  William  Fergusson 
met  with  a  case  of  osseous  tumour  of  the  size  of  a  pigeon^s 
egg,  projecting  from  the  superior  maxilla  of  a  man  aged 
fifty,  who  had  been  the  subject  of  abscess,  and  whose  antrum 
was  still  distended,  though  containing  no  fluid.  Here  it  be- 
came necessary  to  remove  the  tumour  with  the  anterior  wall 
of  the  antrum,  by  which  the  deformity  was  quite  got  rid  of. 
The  case  will  be  found  in  the  Lancet,  June  29,  1850.  A 
case,  under  the  care  of  Mr.  Henry  Smith,  in  which  an  ab- 
scess consequent  on  necrosis  of  a  portion  of  the  jaw  closely 
sinmlated  a  tumour  of  the  antrum,  will  also  be  found  in  the 
British  Medical  Journal,  March  2,  1867. 

Hydroim  Antri,  or  "  dropsy  of  the  antrum,"  is  an  old 
name  (wljich  should,  1  think,  be  abandoned)  for  a  disease 
whicli  has  long  been  recognised,  though,  within  the  last  few 
years,  ojiinions  have  changed  as  to   the  exact  pathology  of 


DISTENSION    OF    THE    ANTRUM.  169 

the  affection.  The  history  of  these  cases  is  one  of  gradual, 
painless  dilation  of  the  upper  jaw_,  until  its  outer  wall  be- 
comes so  thin  as  to  crackle  like  parchment  upon  pressure 
being  made,  or  at  certain  points  being  so  absorbed  that 
fluctuation  is  readily  perceptible.  Occasionally  the  other 
walls  of  the  jaw  yield,  though  more  slowly,  to  the  persistent 
pressure,  the  palate  becoming  flattened,  and  the  nostril 
blocked  by  the  bulging  of  the  internal  wall.  On  the  ex- 
traction of  a  molar  tooth  and  perforation  through  its  socket, 
as  described  under  the  previous  section,  or  more  frequently 
by  an  incision  through  the  osteo-membranous  wall  of  the 
cyst,  a  quantity  of  clear,  or  yellowish  serous  fluid  is  evacu- 
ated, which  frequently  contains  flakes  of  cholesterine  floating 
in  it.  After  the  evacuation  of  the  fluid  the  swelling  ordi- 
narily subsides,  the  maxilla  resuming  its  normal  relations, 
and  the  opening  closing. 

The  old  explanation  of  these  phenomena  was,  that  the 
aperture  between  the  antrum  and  the  nostril  having  become 
accidentally  obstructed,  the  mucous  secretion,  which  was  pre- 
sumed to  be  constantly  taking  place  within  the  cavity,  was 
thought  to  be  imprisoned,  and,  by  its  gradual  accumulation, 
to  produce  the  symptoms  which  have  been  described.  Fol- 
lowing up  this  idea,  we  find  surgeons,  and  among  others 
Jourdain,  of  Paris  (1765),  who  very  accurately  described  the 
affection,  recommending  the  restoration  of  the  nasal  orifice 
by  probing — a  useless  operation,  still  described  in  many 
foreign  manuals  of  operative  surgery  (see  Guerin's  "  Siemens 
de  Chirurgie  Operatoire,"  1855).  Bordenave,  in  his  "  Obser- 
vations on  Diseases  of  the  Maxillary  Sinus"  (Sydenham 
Society's  translation,  1848),  gives  full  details  of  this  method 
of  probing  and  injecting,  but,  after  showing  that  there  is 
great  difficulty  and  uncertainty  in  finding  the  natural  orifice, 
remarks  that  "there  are  very  few  cases  in  which  the  employ- 
ment of  injections  through  the  natural  openings,  in  the 
manner  above  described,  would  effect  a  complete  cure." 
It  is  certain,  however,  that  some  of  these  cases,  and  very 
probably  all  of  them^  originate  in  the  grow^th  of  a  cyst,  or 
cysts,  within  the  antrum,  or  more  commonly  in  the  wall  of 


170  DISEASES    OF    THE    ANTRUM. 

tlie  antruiu,  which  either  grow  to  such  a  size  as  to  be  mis- 
taken for  the  cavity  of  the  antrum  when  opened,  or  break 
into  the  antrum  by  absorption  of  the  cyst-wall,  so  that  on 
subsequent  examination  no  evidence  of  cyst  formation  can 
be  discovered.  This  explanation  is,  as  pointed  out  by 
Coleman,  supported  by  the  fact  that  in  these  cases  of  so- 
called  hydro'ps  antri,  the  contained  fluid  in  no  respect 
resembles  ordinary  mucus,  but  is  invariably  a  clear,  more  or 
less  yellow  fluid,  frequently  containing  cholesterine  in  con- 
siderable quantity.  In  these  respects  it  closely  resembles 
that  found  in  well-marked  cases  of  cystic  growth,  which 
have  been  examined  in  various  stages  of  development. 

Fig.  73. 


A  remarkable  case  of  distension  of  the  antrum  is  narrated 
by  Sir  William  Fergussou,  and  the  preparation  is  preserved 
in  the  King's  College  Museum.  It  was  taken  many  years 
ago  from  a  subject  in  the  dissecting  room,  and  from  the 
person  of  an  old  woman.  The  tumour,  wluch  was  of  very 
large  size,  had  burst  shortly  before  death,  leaving  the 
remarkable  deformity  shown  in  fig.  73  (taken  liy  permission 
from  Sir  W.  Fergusscn's  work  on  Surgery),  which  is  due 
to  the  complete  absorption  of  the  front  wall  of  the  antrum 


CYSTS    IN    THE    ANTHUM.  171 

and  its  collapse^  by  wlucli  a  proiuiucnt  horizontal  lidge  of 
bone,  formed  by  the  upper  wall  of  the  antrum,  has  been  left 
immediately  below  the  orbit.  The  preparation  shows  great 
distension  of  the  antrum,  the  diameter  of  which  varies  in 
different  parts  from  two  to  two  and  a  half  inches,  and  the 
bony  wall  is  so  thinned  out  as  to  resemble  parchment.  The 
glims  are  edentulous.  There  is  no  communication  between 
the  nose  or  mouth  and  the  cavity,  which  is  lined  with  a  mem- 
brane covered  with  laminated  deposit.  (For  these  particulars 
I  am  indebted  to  Dr.  Trimen,  the  late  Curator.)  Whether 
tliis  was  originally  a  case  of  cystic  growth,  or  a  chronic 
abscess,  it  is  impossible  now  to  decide,  but  it  is,  so  far  as  I 
am  aware,  a  unique  post-mortem  specimen  of  tliis  distension. 

Numerous  instances  of  so-called  distension  of  the  antrum 
by  clear  fluid  in  living  patients,  have  been  recorded  from 
time  to  time,  and  occasionally  mistakes  have  been  made  by 
the  surgeon  in  regarding  the  tumour  as  of  a  solid  nature. 
A  very  remarkable  case,  in  which  a  distended  antrum  closely 
simulated  a  solid  growth,  occurred  in  the  practice  of  Sir 
William  Fergusson,  and  the  details  of  the  case  will  be 
found  in  the  Lancet,  June  29,  1850.  Here  the  sm^geon 
made  an  exploratory  puncture  before  commencing  the  more 
serious  operation  ;  but  a  case  has  occurred  within  my  own 
knowledge,  in  which  a  very  able  surgeon  removed  the  upper 
jaw  before  discovering  the  error  of  his  diagnosis. 

M.  Giraldes  would  appear  to  have  been  the  first  author 
upon  the  subject  of  cysts  of  the  antrum,  and  his  thesis 
gained  the  Montyon  prize  in  1853  :  but  Mr.  W.  Adams  may 
fairly  claim  priority  of  investigation,  as  shown  by  specimens 
preserved  in  St.  Thomas's  Museum — as  indeed  is  acknow- 
ledged by  M.  Giraldes.  Lusclika  subsequently  investigated 
the  subject,  and  in  sixty  post-mortem  examinations  found 
cystic  growths  in  the  antrum  five  times,  some  of  them  being 
two  centimetres  in  length.  A  careful  examination  of  the 
antra  of  thirty  subjects,  made  for  me  by  Mr.  Marcus  Beck, 
then  Demonstrator  of  Anatomy  of  University  College,  during 
the  winter  of  1867-68,  failed  to  discover  an  instance  of  the 
kind. 


172 


DISEASES    OF    THE    ANTRUM. 


Mr.  Adams'  specimens,  from  one  of  wliich  the  drawing 
(fig.  74)  was  made,  show  each  a  cyst  of  oval  outline,  attached 
to  the  inner  wall  of  the  antrum,  and  measuring  rather  more 
than  an  inch,  and  three-quarters  of  an  inch  respectively,  in 
their  long  diameters.  These^  of  course,  are  too  small  to 
have  produced  any  symptoms  during  life.  The  specimens 
given  by  M.  Giraldes  in  his  "  Eecherches  sur  les  Kystes 
Muqueux  du  Sinus  Maxillaire,"  from  one  of  which  the 
illustration  (fig.  75)  is  taken,  show  very  varying  degrees  of 
cystic  growth  in  the  nnicous  membrane  of  the  antrum.      In 

Fig.  74. 


one  instance  there  is  a  single  cyst  at  the  floor  of  the  antrum, 
into  which  an  opening  has  been  made,  whilst  in  the  others 
the  cysts  arc  very  numci'ous  and  of  very  variable  sizes, 
depending,  apparently,  ui)on  a  cystic  degeneration  of  the 
entire  mucous  membrane.  M.  Giraldes  explains  the  forma- 
tion of  these  cysts  as  being  due  to  the  dilatation  of  the 
glandular  follicles  of  the  mucous  membrane,  and  urges  that 
the  ordinary  operation  of  tapping  the  antrum  would  be 
useless  in  such  cases,  but  that  it  would  be  necessary  to  open 
up  the  antrum,  so  as  to  get  at  the  seat  of  the  disease. 
Fortunately  these  numerous  cysts  appear  to   be   of   slower 


CYSTS    IN    THE    ANTRUM. 


173 


growth  than  tlie  single  cysts,  for  it  would  be  impossible  to 
extirpate  such  numbers  as  are  liere  seen  (fig.  75),  without 
removing  the  entire  jaw. 

The  contents  of  these  cysts  appear  to  be  at  first  clear 
fluid,  but  of  a  viscid  nature ;  when  more  fully  developed, 
the  fluid  becomes  flaky,  from  the  presence  of  cholesterine, 
and  occasionally  assumes  a  greenish  tint ;  it  may  also  become 
purulent, and  Maisonneuve  has  recorded  (G-azette  des  Hopitaux, 
Jan.  6,  1855)  a  case  where  pressure  on  the  cheek  pro- 
duced a  flow  of  butter-like  fluid  from  the  nose  in  a  young 
woman  who,  for  a  year,  had  suffered  from  a  tumour  of  the 
right  upper  jaw,  which  had  been  pronounced  malignant,  the 

Fig.  75. 


face  beingj  enlarged  and  the  nostril  obstructed.  Here 
puncture  from  the  nostril,  combined  with  pressure  and  in- 
jections, effected  a  cure,  and  the  case  must  be  considered  as 
one  of  cyst  of  the  antrum,  but  whether  a  mucous  cyst,  the 
contents  of  which  had  undergone  solidification,  or  a  separate 
formation,  must  remain  doubtful. 

Treatment. — The  treatment  of  cystic  disease  of  the  jaw 
is  generally  sufficiently  simple.  The  bony  wall  being 
most  commonly,  to  some  extent,  absorbed,  it  is  only  necessary 
to  incise  the  distended  membrane  and  evacuate  the  fluid.  The 
finger  then  passes  readily  into  the  cyst  and  can  examine  its 
interior,  searching  for  any  growth  or  tooth  which  may  be 


174  DISEASES    OF    THE    ANTRUM. 

lodged  within.  "W^ith  curved  scissors  the  opening  can  then 
be  enlarged  Ly  cutting  away  the  membranous  wall,  suffi- 
ciently to  allow  a  free  passage  for  any  discharge.  The  use 
of  a  simple  stimulating  lotion  with  a  syringe  is  then  all 
that  is  required  to  effect  a  cure,  which,  though  slow,  is 
permanent.  I  have  treated  a  considerable  number  of  cases 
of  cyst  of  the  jaw  in  this  manner,  and  with  uniformly  good 
results. 

Broca  ("  Tumeurs,"  vol.  ii.  p.  37)  recommends  to  remove 
tlie  membrane  covering  the  inner  wall  of  the  cyst,  and  gives 
a  case  in  which  Xelaton  discovered  a  plate  of  bony  tissue 
derived  from  a  malformed  tooth  on  the  inner  aspect  of  a 
cyst,  but  this  is  in  most  cases  a  quite  unnecessary  complica- 
tion of  what  is  usually  a  very  simple  matter. 

Polypus  of  the  Antrnra. — This  is  not  a  common  affection, 
though  by  no  means  so  very  rare  as  stated  by  Paget. 
Luschka  has  investigated  the  subject  (Virchow^s  "  Archiv," 
Bd.  viii.  p.  419),  and  found  polypi  five  times  in  sixty  sub- 
jects, some  being  two  centimetres  in  length.  He  gives  a 
drawing,  sliowing  a  large  number  of  these  polypoid  growths 
in  an  antrum,  which  he  considers  to  be  hypertrophies  of  the 
sulmiucous  connective  tissue,  covered  with  mucous  membrane. 
Billroth  also  describes  a  good  example  of  large  polypus  of 
the  antrum  with  a  long  pedicle,  and  regards  it  as  a  very 
rare  affection,  and  there  is  a  good  specimen  in  University 
College  Museum. 

These  polypi  are  closely  allied  apparently  to  the  small 
cystic  growths  in  the  mucous  membrane  of  the  antrum, 
described  by  Giraldes.  Both  affections  consist  essentially  in 
hypertrophy  of  some  elements  of  the  mucous  and  submucous 
tissues.  When  the  connective  or  areolar  tissue  predominates, 
the  fleshy  polypus  is  produced  ;  when  the  glandular  element 
is  especially  affected  we  have  the  cystic  form  produced. 
Intermediately,  when  tlie  fibrous  element  is  very  loose  and 
we  have  some  glandular  hypertrophy,  the  semi-gelatinous 
polypus  is  produced,  which  closely  resembles  the  nasal 
polypus. 

Polypi  of  the  antrum  are  well  supplied  with  blood-vessels, 


POLYPUS  OF  THE  ANTRUM.  175 

and  bleed  freely  when  interfered  with.  In  some  instances 
they  appear  to  have  a  malignant  character,  or  at  least  are 
the  forerunners  of  malio-nant  disease  occurrincf  in  the  antrum 

o  o 

and  jaw.  Vid&l  de  Cassis,  who  ("  Traite  de  Pathologie 
Externe,"  tom.  iii.  p.  492)  totally  denies  the  existence  of 
any  true  polypoid  growths  in  the  antrum,  says  that  what 
have  been  mistaken  for  them  most  frequently  are  colloid 
tumours  of  the  periosteum,  but  believes  that  many  of  the 
examples  are  cases  of  cystic  growth.  Syme  also,  following  the 
example  of  John  Bell,  maintains  that  polypi  in  the  antrum 
always  intrude  from  the  nose,  and  are  never  developed  in 
the  antrum  itself.      {Lancet,  May  10,  1855.) 

Sir  James  Paget  has  put  on  record  (Clinical  Soc.  Trans. 
xii.)  a  case  of  polypus  of  the  antrum  in  which  a  constcint 
flow  of  clear  watery  fluid  from  the  nose  was  the  only 
symptom.  At  the  post-mortem  examination  "  the  floor  of 
the  antrum  was  covered  with  two  broad-based  convex  poly- 
poid growths,  deep  clear  yellow  with  the  fluid  infiltrated  in 
their  tender  tissue,  and  covered  with  exceedingly  thin  smooth 
membrane  traversed  by  branching  blood-vessels.  They 
were  of  rounded  shape,  about  two-thirds  of  an  inch  in 
diameter  and  half  an  inch  in  depth  ;  they  looked  like  very 
thin-walled  cysts,  but  were  formed  of  very  fine  membranous 
or  filamentous  tissue,  infiltrated  with  serum." 

Ordinarily  the  symptoms  of  polypi,  no  less  than  of  cysts 
of  the  antrum,  only  become  developed  when  the  growth  is 
of  sufficient  size  to  encroach  upon  the  neighbouring  cavities, 
or  produce  distension  and  absorption  of  the  front  of  the 
antrum.  The  most  common  situation  for  the  jiolypus  to 
show  itself  is,  as  might  be  expected,  the  nose,  since  the 
tumour  readily  induces  absorption  of  the  thin  nasal  wall  of 
the  antrum.  Here  it  closely  resembles  the  ordinary  nasal 
polypus,  and  Sir  William  Fergusson  mentions  ("  Practical 
Surgery,"  p.  561)  two  cases  of  the  kind  in  which  this  had 
occurred,  one  being  in  his  own  practice.  In  that  instance 
he  soon  found  that  he  had  attacked  a  tumour  of  the  antrum, 
which,  in  consequence  of  its  deep  and  firm  attachment,  and 
the  great  hcemorrhage    attending  it,  he    did    not    entirely 


176  DISEASES    OF   THE    ANTRUM. 

remove.  The  disease  returned,  and  lie  again  operated,  on 
this  occasion  using  great  force,  and  wrenched  out  the  whole 
mass,  not  without  some  fear  of  the  consequences.  The 
case,  however,  did  well,  and  after  ten  years  the  disease  had 
not  returned. 

In  the  Medical  Times  and  Gazette,  March  18,  1860,  is 
a  report  of  another  case  in  which  the  same  surgeon  re- 
moved a  vascular  fibrous  polypus  of  the  antrum  which  had 
projected  into  the  nostril,  by  laying  open  the  front  wall  of 
the  cavity,  and  with  strong  forceps  tearing  out  the  tumour 
bit  by  bit. 

I  had,  during  1866,  the  opportunity  of  watching  the  case 
of  a  patient  who  had  had  a  polypus  partially  removed  by 
the  nose  on  several  occasions,  and  from  whom  Mr.  Holthouse 
removed  an  entire  growth  a  year  and  a  half  before  that 
date.  He  re-appeared  with  a  swelling  of  the  jaw,  evidently 
due  to  distension  of  the  antrum  by  some  soft  growth,  and 
he  had  also  a  soft  tumour  on  the  forehead.  These  were 
doubtless  cancerous,  for  his  strength  failed,  and  he  sank 
after  some  months,  but  unfortunately  his  relations  would 
not  permit  a  post-mortem  examination  to  be  made. 

Hypertrophy  of  the  glandular  tissue  of  the  mucous  mem- 
brane appears  capable  of  producing  tumours  of  a  friable 
description,  which  may  fill  up  the  antra  on  both  sides,  as  in 
a  case  recorded  by  M.  Demarquay  {Gazette  Medicate  dc 
Paris,  November  4,  1857).  Here  the  patient  had  a  large 
tumour  on  each  side  of  the  nose,  the  passages  of  which  were 
completely  obstructed,  and  his  right  eye  was  protruded  from 
the  orbit.  M.  Demarquay  removed  the  front  walls  of  the 
antra,  and  extirpated  two  masses  of  very  friable  tissue  of  a 
greyish-white  colour,  in  which  the  vascular  tissue  was  not 
abundant.  M.  liobin,  who  examined  the  growths,  pro- 
nounced them  to  be  the  result  of  an  hypertrophy  of  the 
glandular  element  of  the  mucous  membrane  of  the  antrum. 

A  curious,  and  I  believe,  unique  case  of  falling  in  of  the 
antrum,  recorded  by  Mr.  White  Cooper,  may  be  conveniently 
mentioned  here,  since  the  depression  of  the  wall  of  the 
cavity  depended,  no  doubt,  upon  some  alteration  going  on 


FALLING   IN    OF    THE    ANTRUx\L  177 

in  its  interior — possibly  the  absorption  of  some  fluid  which 
had  previously  induced  thinning  of  the  bones.  The  patient 
was  brought  before  the  Medical  Society  of  London  in  1851, 
and  Mr.  Cooper  has  kindly  given  me  the  following  details  of 
her  case  : — 

"  I  first  saw  Margaret  Ryan  (aged  twenty-seven)  May 
22,  1849. 

"  Complained  of  the  tears  running  over  the  left  cheek, 
first  perceived  about  a  week  previously. 

"  Seven  years  ago  first  observed  a  black  mark  round  the 
lower  part  of  the  left  eyelid  ;  without  pain,  weakness  of  eye, 
or  toothache.  Gradually  and  almost  imperceptibly  flattening 
of  the  cheek  came  on. 

"  The  appearance  presented  was  that  of  a  deep  depression 
between  the  malar  bone  and  nose,  precisely  as  if  a  portion  of 
the  superior  maxillary  bone  had  been  cut  away. 

"  It  was  bounded  superiorly  by  the  inferior  margin  of  the 
orbit,  which  partook  of  the  depression ;  inferiorly  by  the  base 
of  the  alveolar  process ;  and  externally  by  the  malar  bone. 
As  compared  with  the  other  cheek,  the  dimensions  were  as 
follows : — From  bridge  of  nose  over  deepest  point  of  de- 
pression, one  inch  four-tenths,  or  nearly  an  inch  and  a  half ; 
right  side  to  corresponding  point  just  one  inch. 

"  There  was  a  peculiar  dusky  hue  about  the  depression, 
especially  toAvards  the  upper  part.  The  cuspid  and  bicuspid 
teeth  were  removed  with  considerable  difliculty,  the  roots 
showing  thickening  of  periosteum. 

"  No  change  was  visible  at  the  expiration  of  twelve 
months." 


N 


178 


CHAPTER    XII. 

CYSTS    OF   TEETH DENTIGEROUS  CYSTS. 

Cysts  in  connection  with  the  teeth  may  be  classed  under  t\A'o 
heads  : — 1st,  cysts  connected  with  the  roots  of  fully  de- 
veloped teeth,  and  2ndly,  cysts  connected  with  imperfectly- 
developed  teeth — to  which  the  term  "  Dentigerous  cysts" 
has  been  applied  in  modern  times.  Both  kinds  may  occur 
in  either  jaw,  and,  in  the  case  of  the  upper  jaw,  may  be 
confounded  with  collections  of  fluid  in  the  antrum,  or  may 
secondarily  involve  that  cavity. 

Cysts,  of  small  size,  in  connection  with  the  fangs  of  per- 
manent teeth,  are  frequently  found  on  their  extraction,  but 
give  rise  to  no  symptoms  demanding  surgical  interference, 
though  sometimes  they  cause  pain  from  pressure  on  the 
dental  nerves.      Occasionally,  however,  they  grow  to  a  large 

Fig.  76.  Fig.  77.  Fig.  78. 


size,  in  which  case  they  produce  absorption  of  the  containing 
alveolus,  and  give  rise  to  a  prominent  swelling.  They  lie 
beneath  the  periosteum  of  the  fang,  and  hence  have  been 
named  by  Magitot  (Arch.  Gen.  de  M^decine,  1872-73)  peri- 
osteal cysts.  Tlie  contained  fluid  is  rich  in  cholesterine. 
Three  specimens  of  cyst  connected  with  the  fangs  of  teeth, 


CYSTS    OF    TEETH.  179 

for  which  I  was  indebted  to  Mr.  Holljorow  King,  accom- 
panied this  essay,  and  are  now  in  the  Museum  of  the  College 
of  Surgeons  (2161).  Two  of  them  (figs.  Ill ,  78)  are  quite 
small  (one  being  remarkable  for  the  length  of  its  pedicle), 
the  third  (fig.  1^)  is  of  the  size  of  a  hazel-nut,  and  was  torn 
in  extraction.  The  contents  of  the  cyst  were  found  on 
microscopic  examination  to  consist  of  degenerating  pus ; 
their  walls  were  formed  of  fibrous  and  granulation  tissues, 
and  they  had  no  epithelial  lining.  This  would  confirm  the 
view  of  Mr.  Tomes,  that  the  morbid  process  is  probably 
identical  with  that  resulting  in  the  formation  of  alveolar 
abscess,  but  being  less  acute,  a  serous  cyst  is  formed  instead 
of  a  suppurating  sac.  In  the  Museum  of  the  College  of 
Surgeons  is  another  specimen  of  a  vascular  thick-walled 
cyst,  attached  to  one  side  of  the  fang  of  an  incisor  tooth 
(2161a). 

Large  cysts,  which  produce  more  or  less  absorption  of  the 
outer  wall  of  the  maxilla,  are,  in  my  experience,  very  common 
consequences  of  the  retention  of  diseased  teeth,  but  seem  to 
give  surprisingly  little  inconvenience  to  the  patients,  even 
when  of  large  size  and  producing  considerable  deformity  of 
the  face.  They  are  commonly  confounded  with  cystic  dis- 
tension of  the  antrum. 

Dupuytren  remarks  that  "  morbid  changes  in  the  roots  of 
the  teeth  give  rise  to  the  formation  of  serous  cysts,  which 
are  most  frequently  met  with  in  the  alveoli  of  the  upper 
canines,  and  in  some  instances  acquire  a  very  large  size, 
even  equal  to  that  of  the  antrum.  In  such  cases  the  root 
of  the  tooth  is  found  diseased  and  inclosed  within  the  cyst, 
which  adheres  to  the  alveolar  cavity,  and  (when  small 
enough)  usually  accompanies  the  tooth  in  its  extraction ; 
but  if  left  behind,  a  suppurative  process  is  established,  wliich 
continues  for  a  long  time.  The  fluid  yielded  by  these  cysts 
is  sometimes  very  thick,  and  in  other  instances  of  a  serous 
character,  and  their  inner  surface  is  as  smooth  as  that  of  the 
serous  membranes"  ("  On  Diseases  of  Bone,"  Sydenham 
Society's  Translation,  p.  440). 

Of  this  kind  probably  also  was  the  case  mentioned  by 

N  2 


180  CYSTS    OF    TEETH. 

Sir  J.  Paget  ("  Surgical  Pathology/'  p.  402),  of  a  woman,  aged 
thirty-eight,  who  had  a  tumour  simulating  a  collection  of 
fluid  in  the  antrum,  but  which  projected  beneath  the  mucous 
membrane  of  the  upper  jaw  above  the  teeth,  and  had 
existed  six  years.  An  incision  evacuated  an  ounce  of  turbid 
brownish  fluid,  sparkling  with  crystals  of  cholesterine,  and 
it  then  appeared  that  there  was  no  connection  with  the 
antrum,  but  that  it  rested  in  a  deep  excavation  in  the  alveolar 
border  of  the  jaw.  So  also  the  case  mentioned  by  the  same 
author  in  connection  with  the  incisor  teeth. 

Delpech  relates  a  case  in  which  a  membranous  cyst  con- 
tained three  ounces  of  fluid,  but  its  interior  bore  no  re- 
semblance to  the  interior  of  the  antrum ;  and  Stanley 
(p.  300)  narrates  a  case  of  Sir  W.  Lawrence's  of  large  cyst 
projecting  in  the  situation  of  the  antrum,  and  containing  a 
glairy  fluid  with  shining  particles  in  it,  and  regards  both 
cases  as  instances  of  cysts  connected  with  the  teeth,  although 
it  appears  more  probable  that  they  were  examples  of  cyst  in 
the  antrum,  such  as  have  been  already  described. 

A  case^  which  I  have  little  doubt  originated  in  a  cyst  in 
connection  with  the  incisor  teeth,  but  in  which  the  antrum 
had  become  secondarily  involved,  has  lately  been  under  my 
own  care.  The  patient,  a  woman  aged  forty,  had  a  fluc- 
tuating swelling,  noticed  for  two  years,  immediately  above 
the  incisor  teeth,  which  were  decayed  even  with  the  gum. 
On  incising  it,  a  quantity  of  yellowish  glairy  fluid  exuded, 
and  a  probe,  when  introduced,  evidently  passed  into  the 
antrum.  From  the  position  of  the  cyst,  and  its  close  proxi- 
mity to  the  incisor  teeth,  I  have  no  doubt  it  originated  from 
them,  and  found  its  way  into  the  antrum  by  absorption  of 
the  bony  wall.  Tlie  patient  would  not  consent  to  any 
operation  for  the  cure  of  the  disease,  whicli  gave  her  little 
inconvenience. 

Fischer,  of  Ulm  (Gurlt's  "  Jahresbericht,"  1859,  p.  151), 
has  narrated  three  cases  of  cyst  connected  with  tlie  fangs  of 
teeth,  in  one  of  whicli  he  had  the  opportunity  of  making  a 
post-mortem  examination.  After  the  removal  of  the  facial 
wall  of  tlie  antrum,  there  appeared  a  cyst  connected  with 


CYSTS    OF    TEETH.  181 

the  apex  of  the  posterior  molar  tootli,  which  filled  the  whole 
antrum  without,  however,  adhering  to  the  mucous  mem- 
brane. This  consisted  of  a  perfectly  closed  serous  bag  of 
§'"  thickness,  with  a  smooth  inner  surface,  and  containing 
a  yellowish  serous  fluid,  which  grew  from  the  periosteum  of 
the  apex  of  the  root  of  the  tooth. 

The  clinical  history  of  cysts  connected  with  tlie  teeth  is 
that  of  painless  expansion  of  the  alveolus  of  either  jaw,  but 
more  frequently  of  the  upper,  with  crackling  of  the  bone  on 
pressure  and  ultimate  absorption  of  the  bony  wall.  The 
cyst  then  presents  a  bluish  appearance  through  the  distended 
mucous  membrane,  and  if  large,  gives  distinct  evidence  of 
fluctuation. 

Treatment. — An  incision  into  the  cyst  evacuates  a  dark- 
coloured  clear  fluid,  unless  inflammation  should  have  been 
excited,  when  the  contents  become  purulent.  It  is  advisable 
to  cut  away  the  thin  outer  wall  of  the  cyst  freely  with 
scissors,  or,  if  necessary,  with  bone-forceps,  so  that  the  cavity 
may  granulate  up.  If  an  incision  only  is  made,  the  edges 
are  apt  to  fall  together  and  re-unite  with  a  reproduction  of 
the  fluid,  unless  an  india-rubber  drainage-tube  is  inserted, 
which  can  be  attached  by  a  thread  to  a  neighbouring  tooth. 
Single  Cysts  in  the  lower  jaw  as  in  the  upper,  may  origi- 
nate in  connection  with  the  fully-developed  teeth,  and  as  in 
the  case  of  dentigerous  cysts,  may  give  rise  to  the  suspicion 
of  a  more  severe  affection.  In  April,  1867,  a  case  of  the 
kind  occurred  in  King's  College  Hospital  in  the  person  of  a 
boy  aged  ten,  who  appeared  to  have  a  solid  tumour  of  the 
body  of  the  lower  jaw  on  the  right  side,  rather  larger  than 
a  pigeon's  egg.  Sir  Wilham  Fergusson  discovered  a  slight 
yielding  of  the  osseous  wall,  which  crackled  upon  being 
pressed,  and  upon  extracting  a  neighbouring  tooth  a  quantity 
of  glairy  fluid  escaped.  The  treatment  was  completed  by 
cutting  away  a  part  of  the  expanded  outer  plate  of  the 
bone,  and  making  the  wound  heal  from  the  bottom. 

According  to  Broca  ("  Traite  des  Tumeurs,"  vol.  ii.  p.  35)  the 
great  majority  of  cysts  of  the  jaws  have  their  origin  in  tooth 
follicles.     These  are  shut  sacs,  but  they  do  not  enclose  a  true 


182  CYSTS    IN    THE    LOWER    JAW. 

cavity,  for  the  space  between  the  wall  and  the  outer  surface 
of  the  dental  papilla  is  occupied  by  the  enamel-organ,  an 
organized  body,  but  very  soft  and  gelatinous,  apt  to  disappear 
under  morbid  influences,  and  thus  leaving  in  the  follicle  a 
cavity  ready  to  be  transformed  into  a  cyst.  Dental  cysts 
may  originate  in  the  follicles  of  the  first  or  second  dentition, 
or  in  the  follicles  of  supernumerary  teeth.  Their  contents 
are  ordinarily  clear  fluid,  sometimes  bloody,  occasionally 
filamentous  or  gelatinous,  and  still  more  rarely  they  contain 
a  sebaceous  matter  like  mastic,  composed  almost  entirely  of 
epithelium. 

But  periosteal  cysts  occur  in  the  lower  jaw  without  any 
apparent  immediate  connection  with  the  teeth,  though  very 
possibly  some  irritation  connected  with  these  organs  may  have 
been  the  original  cause  of  the  mischief,  "  The  patient  finds 
that  he  has  a  slowly-growing  tumour  of  the  jaw,  which  is 
painless,  and  gives  him  no  trouble  except  from  the  deformity. 
The  outer  plate  yields  ordinarily  to  the  pressure  of  the 
growing  cyst,  and  thus  a  prominent  smooth  tumour  is 
formed,  over  which  the  skin  is  freely  movable.  When  the 
bony  wall  is  sufficiently  attenuated,  the  peculiar  crackling 
already  described  may  be  produced  on  pressure,  and  if  the 
disease  is  still  unchecked  the  bone  becomes  entirely  ab- 
sorbed, and  nothing  but  a  membranous  cyst,  with  particles 
of  osseous  matter  imbedded  in  it,  remains.  Of  this  a 
most  remarkable  specimen  from  a  woman,  set.  forty-five,  is 
to  be  seen  in  St.  George's  Hospital  Museum  (II.  150).  The 
cyst  is  for  the  most  part  single,  and  contains  merely  fluid, 
which  may  be  clear  or  more  or  less  coloured.  Dupuytren 
narrates  several  cases  of  the  kind  ("  Diseases  of  Bone," 
Sydenham  Society,  p.  437),  from  some  of  which  only 
reddish-coloured  serum  escaped  on  their  being  opened, 
whilst  in  others  a  fibroid  growth,  and  in  one  osseous  nodules, 
were  found  within  them.  There  is  a  good  example  of  a 
single  cyst  for  which  a  piece  of  the  entire  thickness  of  the 
lower  jaw  was  excised  in  St.  George's  Museum,  of  which 
the  following  are  the  particulars  : — The  patient  had  had  a 
tumour,  supposed  to  be  an  epulis,  removed  from  the  same  spot 


DENTIGEROUS    CYSTS.  183 

two  years  before,  and  tlie  disease  had  been  growing  since 
that  time.  When  admitted  the  tumour  was  found  to  be  a 
firm  oval  growth,  about  the  size  of  an  orange,  connected 
with  the  outer  surface  of  the  right  inferior  maxilla.  It  was 
evidently  cystic,  and  there  was  an  indistinct  sensation  of 
fluctuation.  The  tumour,  as  well  as  the  portion  of  bone 
from  which  it  grew,  was  removed  by  an  incision  in  the 
median  line.  The  extent  of  lower  jaw  removed  was  from 
the  lateral  incisor  tooth  on  the  left  side  to  the  angle  of  the 
jaw  on  the  right. 

The  accompanying  drawings  show  a  case  of  unilocular 
cyst  of  the  lower  jaw,  for  which  Sir  William  Fergusson  re- 

FiG.  79. 


moved  a  large  portion  of  the  bone.  Fig.  79  shows  the 
growth,  and  figs.  80  and  81  the  patient  before  and  after  the 
operation.      (See  "  Practical  Surgery,"  p.  666.) 

Cysts  in  connection  with  undcvelo'ped  teeth,  or  Dentigerous 
Cysts  (coronary  cysts  of  Magitot)  may  occur  in  either  jaw. 
These,  as  already  mentioned,  may  suppurate  and  give  rise  to 
abscess,  which  may  be  confounded  with  suppuration  within 
the  antrum,  or  may  project  into  the  antrum,  filling  the  cavity 
or  communicating  with  it. 

Dentigerous  cysts  arise  in  connection  with  teeth  which 
from  some  cause  have  remainad  within  the  jaw,  and  have 
undergone  a  certain  amount  of  irritation.  They  are  almost 
invariably  connected  with  permanent  teeth,  though  ]\Ir. 
Salter  mentions  a  case  in  connection  with  a  temporary  molar 


184  CYST    IN    THE   LOWER    JAW. 

Fig.  80. 


Fig.  81. 


DENTfGEROUS    CYSTS.  185 

occurring  in  the  practice  of  Mr.  Alexander  Edwards,  late 
of  Edinljurgli  ;  and  in  a  remarkable  specimen  belonging  to 
Mr.  Cartwright,  which  will  be  afterwards  referred  to,  the 
tooth  is  a  supernumerary  one.  I  have  also  myself  met  with 
an  example  of  cyst  connected  with  a  temporary  tooth  in  a 
boy  of  four  years,  brought  to  me  by  Mr.  C.  J.  Fox.  In  this 
case  the  temporary  right  canine  tooth  was  wanting,  and  there 
was  a  cyst  developed  in  its  situation,  on  cutting  into  which 
I  extracted  seven  small  irregular  nodules  of  dentine  and 
enamel,  but  no  complete  tooth,  this  being  therefore  an 
example  of  the  odonto-plastic  cyst  of  Magitot. 

Mr.  Tomes  explains  the  formation  of  cysts  in  connection 
with  retained  teeth  by  referring  to  the  fact  that  when  the 
development  of  the  enamel  of  a  tooth  is  completed,  its  outer 
surface  becomes  perfectly  detached  from  the  investing  soft 
tissue,  and  a  small  quantity  of  transparent  fluid  not  uncom- 
monly collects  in  the  interval  so  formed.  This  fluid 
ordinarily  is  discharged  when  the  tooth  is  cut,  but  when 
from  some  cause  the  eruption  of  the  tooth  is  prevented,  it 
increases  in  quantity,  gradually  distending  the  surrounding 
tissues  in  the  form  of  a  cyst. 

For  further  microscopic  details  and  for  a  full  discussion 
of  Magitot 's  views,  I  may  refer  to  Mr.  F.  Eve's  very  able 
lecture  on  "  Cystic  Tumours  of  the  Jaws,"  delivered  at  the 
Eoyal  College  of  Surgeons,  and  published  in  the  British 
Medical  Journal,  January  6,  1883. 

Mr.  Salter,  in  his  work  on  "Dental  Pathology  and  Sur- 
gery," has  collected  several  cases  of  dentigerous  cyst,  which 
were  recognized  and  treated  during  life.  Thus  Jourdain 
records  three  cases,  one  in  a  girl  of  seventeen,  in  whom 
the  first  and  second  right  upper  permanent  molars  were 
inverted  and  the  surrounding  cyst  had  involved  the  antrum  ; 
a  second  in  a  man  of  sixty,  connected  with  a  bicuspid  tooth 
of  the  upper  jaw ;  and  the  third  in  a  girl  of  thirteen,  con- 
nected with  an  upper  lateral  incisor.  Dupuytren  and  Bransby 
Cooper  each  met  with  a  case  in  the  upper  jaw.  Dupuytren's 
case,  which  was  shown  to  him  by  M.  Loir,  being  a  remark- 
able instance  of  a  cyst  developed  between  the  plates  of  the 


186 


DENTIGEROUS   CYSTS. 


palatine  process  of  the  upper  jaw  (sec  Dupuytren  "  On 
Diseases  of  Bone/''  Sydenham  Society's  translation,  p.  438.) 

Professor  Baiim  also  met  with  an  extraordinary  case 
in  a  woman  aged  thirty-eight,  both  of  whose  antra  were 
enormously  dilated  by  cysts,  from  one  of  which  a  canine 
tooth,  and  from  the  other  a  molar  tooth,  was  removed.  Mr. 
Salter  gives  two  cases  of  his  own,  which  will  be  found  at 
length  in  the  "  Guy's  Hospital  Eeports^  1859,-"  one  depend- 
ing upon  the  impaction  of  a  wisdom  tooth  in  the  lower  jaw 
of  a  man  aged  twenty-two,  and  the  other  in  a  girl  of 
eighteen,  who  had  an  elastic  fluid-containing  tumour  in  .the 
incisive  region  of  the  upper  jaw  connected  with  a  permanent 
incisor  tooth,  the  fang  of  wliich  was  not  developed,  and  whose 
place  was  occupied  by  a  temporary  tooth. 

Inversion  of  the  tooth  appears  to  be  a  frequent  accom- 
paniment, or  rather  the  cause  of  these  cysts,  and  occurred 
in  one  of  the  cases  narrated  by  Jourdain,  and  in  those  of 
Dupuytren  and  Bransby  Cooper.  Mr.  Tomes  ("Dental 
Surgery")  has  recorded  a  similar  case  in  a  girl  of  sixteen. 


Fig.  82. 


,V, V  „„,i,'  "■ 


who  had  a  swelling  around  the  second  molar  tooth  of  the 
lower  jaw,  whicli  proved  to  be  a  cyst.  After  being  tapped, 
the  cyst  suppurated,  and  the  extraction  of  the  tooth  became 
necessary,  when  the  inverted  crown  of  the  third  molar  was 
found  lodged  between  the  expanded  fangs  of  the  second 
molar  tooth,  the  two  being  united  by  dentine,  and  having 
one  common  pulp-cavity,  as  seen  in  the  accompanying 
drawing,  fig.  82,  from  Mr.  Tomes'  work. 

Cases  of  dentigerous  cysts  may  be  mistaken  for  solid 
tumours.  Thus  Gensoul,  of  Lyons,  has  recorded  the  case 
of  a  girl  of  thirteen,  whose  antrum  was  distended  with  a 


DENTTGEHOUS   CYST    OF   LOWER   JAW.  187 

large  collection  of  yellow  fluid  and  contained  a  canine  tooth 
attached  to  its  wall,  in  whom  he  had  made  the  incisions 
necessary  for  the  removal  of  the  tumour  before  he  discovered 
its  nature.  Mr.  Syme  also  has  related  {Edinhurgh  Medical 
and  Surgical  Journal,  1838)  the  case  of  a  woman  eet.  thirty- 
one,  on  whom  he  operated  for  a  tumour  of  the  upper  jaw  of 
four  months'  standing,  by  laying  open  the  cheek  and  remov- 
ing the  tumour  with  the  bone-forceps.  "  The  tumour  was 
found  to  consist  of  a  dense  cyst  lined  throughout  with  earthy 
matter  in  a  crystalline  form,  and  containing  a  clear  glairy 
fluidj  together  with  the  crown  of  a  tooth,  apparently  the 
lateral  incisor."  In  a  cavity  beyond  the  tumour  was  found 
a  fully  formed  canine  tooth,  encrusted  with  a  thin  plate  of 
bone.  The  teeth  are  said  to  have  belonged  to  the  tempo- 
rary set. 

When  dentigerous  cysts  occur  in  the  lower  jaw  they 
form  more  isolated  and  prominent  tumours  than  in  the  case 
of  the  upper  jaw,  and  in  some  cases  the  projecting  bony 
wall  has  been  removed.  In  St.  Bartholomew's  Museum 
is  a  specimen  of  the  kind  (I.  119),  consisting  of  a  portion 
of  a  bony  cyst,  which  was  removed  by  Mr.  Earle  from  the 
external  and  lateral  part  of  a  lower  jaw.  The  cyst  is 
lined  with  a  thick  and  soft  membrane,  which  has  been  in 
part  separated  from  it.  The  cavity  of  the  cyst  was  filled 
with  a  glairy  fluid,  and  at  the  bottom  of  it  a  canine  tooth 
of  the  second  set  was  adherent  to  the  lining  membrane. 
The  case  is  referred  to  by  Stanley,  who  gives  an  accurate 
drawing  of  the  preparation.  In  the  Museum  of  the  CoUege 
of  Surgeons  tliere  is  a  very  similar  preparation  (2196) 
showing  a  bony  cyst  of  oval  shape,  one  inch  in  its  long 
diameter,  lined  with  a  thick  well-formed  membrane,  con- 
taining an  imperfectly  formed  bicuspid  tooth,  which  was 
removed  by  Mr.  Wormald  from  the  lower  jaw  of  a  female 
aged  seventeen,  whose  case  will  be  found  in  the  Lancet, 
June  22,  1850. 

When  the  cyst  occurs  in  the  lower  jaw,  and  is  less  pro- 
minent than  in  the  two  cases  already  mentioned,  giving  rise 
rather  to  a  general   expansion  of  the  bone  than  a   distinct 


188 


DENTIGEROUS    CYSTS. 


tumour,  the  disease  luay  be  mistaken  for  a  solid  tumour  of 
the  lower  jaw.  A  case  of  this  kind  occurred  to  that  excel- 
lent surgeon,  the  late  Mr.  S.  W.  Fearn,  of  Derby,  who 
had  the  courage  and  honest}'  to  publish  the  case  {British 
Medical  Journal,  Aug.  27,  1864),  and  to  whom  I  was 
indebted  for  the  very  valuable  preparation  (College  of 
Surgeons  Museum,  2195),  from  which  the  drawings,  figs.  83 
and  84,  were  made. 

Mr.  Team's  patient  was  a  girl  of  thirteen,  who  had  a 
large  resistant  tumour  of  the  left  side  of  the  lower  jaw, 


Fig.  83. 


Fig.  84. 


which  had  been  growing  six  months.  There  was  some 
enlargement  also  of  the  right  side,  and  the  teeth  there  were 
very  ii-regular.  The  teeth  on  the  left  side  had  been  ex- 
tracted, witli  the  exception  of  the  second  molar  and  a  tem- 
])orary  molar.  No  opening  could  lie  detected  in  the  tumour, 
though  thei'C  was  a  constant  oflensive  discharge  from  its 
surface.  ]\lr.  Fearn  removed  the  left  half  of  the  jaw  from 
the  syn)physis  to  the  articulation,  and  on  division  of  the 
Ijf'ne  with  tlie  saw,  a  quantity  of  fo'tid  pus  escaped.  The 
tumour  (fig.  83)  proved  to  be  a  bony  cyst  formed  by  the 


DENTIGEROUS    CYST   OF    LOWER    JAW 


189 


expansion  of  the  two  plates  of  the  j'aw,  Avhich  extended  for 
some  distance  to  the  right  of  the  symphysis  (a  very  unusual 
occurrence).  The  cavity  is  lined  with  a  thick  vascular 
membrane,  and  at  the  bottom  the  canine  tooth  will  be  seen 
projecting  from  the  wall.  The  case  was  evidently  therefore 
one  of  dentigerous  cyst,  due  to  the  non-development  of  the 
canine  tooth,  the  contents  of  which  had,  from  some  cause, 
become  purulent.  The  mental  foramen,  with  the  nerve 
emerging,  is  still  visible  in  the  preparation  and  drawing  (fig. 
81).      The  patient  made  a  good  recovery. 

A  very  similar  case  is  recorded  by  Dr.  Forget,  in  his 
essay  on  "  Les  Anomalies  Dentaires  et  leur  influence  sur  la 
production  des  Maladies  des  Os  Maxillaires,"  1859,  which 

Fig.  85. 


is  translated  by  Mr.  E.  T.  Hulme,  in  the  Dental  Bciicv, 
1860.  The  patient  was  a  woman  aged  thirty,  who  had  a 
tumour  on  the  right  side  of  the  lower  jaw,  of  tlie  size  of  a 
hen's  egg,  extending  from  the  lateral  incisor  to  the  base  of 
the  coronoid  process,  which  had  been  growing  ten  years. 
M.  Lisfranc  removed  half  the  jaw,  and  the  patient  made  a 
goed  recovery.     An  examination  of  the  tumour  showed  it 


190 


DENTIGEROUS    CYSTS. 


to  be  a  cyst,  at  the  bottom  of  which  lay  the  wisdom  tooth, 
the  crown  projecting  downwards  into  it,  the  fang  being- 
inverted  and  fixed  in  the  base  of  the  coronoid  process.  In 
the  illustration  (fig.  85),  (for  which  I  am  indebted  to  Mr. 
Hulnie),  the  cyst  has  been  opened,  the  internal  wall,  h, 
being  left ;  a  marks  the  position  of  the  tooth,  and  c  the 
inferior  dental  canal,  which  has  been  opened  to  show  its 
non- communication  with  the  cyst. 

M.  Legouest  brought  under  the  notice  of  the  Soci^te  de 
Chirurgie  de  Paris,  in  1862,  a  very  similar  case,  which  had  the 
peculiarity  of  pulsating  at  one  point  synchronously  with  the 
radial  pulse.  The  supposed  tumour  proved  to  be  a  denti- 
gerous  cyst  containing  two  teeth,  the  pulsation  having  been 


Fig.  86. 


Fig.  87. 


due  to  the  great  vascularity  of  the  membrane  covering  it, 
and  the  great  pain  which  had  been  experienced,  to  the  fact 
that  the  dental  canal  was  opened,  and  the  nerve  pressed 
upon  by  the  cyst.     {Gazette  des  Hupitaux,  Aug.  7,  1862.) 

In  the  Annali  Universali  di  Medicina  for  May,  1867,  Sig. 
Bottini,  of  Novara,  has  recorded  a  case  of  "  subperiosteal 
and  subcapsular  disarticulation"  of  the  left  half  of  the 
lower  jaw  of  a  woman  ict.  twenty-three,  for  what  proved  a 
dentigerous  cyst  in  connection  with  the  wisdom  tooth. 

Mr.  Underwood  has  allowed  me  to  have  the  accompany- 


DIAGNOSIS    OF    DENTIGEROUS    CYSTS.  191 

ing  drawing  (fig.  86),  taken  from  the  model  of  a  preparation 
which  he  possesses,  showing  very  beautifully  a  cyst  of  the 
lower  jaw,  which  was  removed  by  M.  Maisonneuve  by  saw- 
ing through  the  bone  at  two  points.  The  canine  tooth  is 
seen  lying  horizontally  at  the  bottom  of  the  cyst.  The 
patient,  aged  fifty-six,  had  a  swelling  in  the  lower  jaw  near 
the  chin,  and  an  opening  formed  behind  one  of  his  front 
teeth,  from  which  a  saline  fi-uid  escaped.  The  man  made  a 
good  recovery  from  the  operation.  (Vide  British  Journal 
of  Dental  Science,  186.2,  p.  562). 

Dentigerous  cysts,  like  other  cysts,  may  undergo  altera- 
tion, not  only  of  the  contents^  but  of  the  cyst-wall.  The 
opportunities  for  recognizing  such  changes  are  exceedingly 
rare,  and  the  only  known  specimen  of  the  kind  is  one  in  the 
possession  of  Mr.  Samuel  Cartwright,  which  shows  calcifi- 
cation of  the  cyst-wall.  The  preparation  (a  reduced  draw- 
ing of  which  (fig.  87)  is  taken  from  Mr.  Catlin's  paper  on 
the  Antrum)  is  one  of  the  right  superior  maxilla,  which, 
having  been  opened,  shows  a  bony  cyst  within  the  antrum 
and  attached  to  its  floor,  but  unconnected  with  it  elsewhere. 
The  cyst  has  been  opened,  and  contains  a  supernumerary 
tooth  loose  in  its  cavity,  though  no  doubt  originally  attached 
to  its  base.  This  is  clearly  a  case  of  dentigerous  cyst  which 
has  undergone  calcification,  and  which,  had  it  been  expanded 
to  a  greater  degree  before  this  change  took  place,  would  in 
all  probability  have  been  insej^arably  united  with  the  walls 
of  the  antrum. 

The  diagnosis  of  dentigerous  cysts  from  other  cysts  is 
exceedingly  difficult  until  they  are  opened,  as  indeed  is  the 
recognition  of  any  form  of  cyst.  A  careful  examination  of 
the  mouth  may  reveal  the  absence  of  a  permanent  tooth,  or, 
as  in  one  of  Mr.  Salter's  cases,  may  show  a  temporary  tooth 
occupying  a  permanent  position,  and  this  would  direct  the 
mind  of  the  surgeon  to  the  possible  existence  of  a  denti- 
gerous cyst.  On  the  other  hand,  however,  it  must  be 
remembered  that  teeth  may  be  wanting  without  being  con- 
nected with  any  disease ;  thus  I  am  acquainted  with  a  family 
who w  have  the   hereditary  peculiarity  of  a  single   bicuspid 


19: 


dentigeroUkS  cysts. 


tooth  oil  eacli  side.  When  a  cyst  is  sufficiently  expanded 
for  the  wall  to  yield  under  the  finger  with  tlie  characteristic 
parchment-like  crackle,  there  can  he  no  difficulty  in  its 
recognition,  but  without  this  it  is  impossible  in  all  cases  to 
distinguish  between  a  cyst  and  a  slow-growing  solid  tumour. 
Under  these  circumstances,  it  is  well  to  insist  upon  the 
propriety  of  making  an  exploratory  puncture  in  all  cases 
which  are  not  obviously  solid  growths,  and  have  sprouted  so 
that  their  nature  can  be  certainly  recognized.  The  puncture 
being  made  within  the  mouth  will  be  of  no  moment  should 
a  more  severe  operation  subsequently  be  necessary. 

The  accompanying  engraving  (fig.  88)  shows  a  cyst  of  the 
lower  jaw  occurring  in  a  man  aged  thirty-four,  who  was  under 

Fig.  88. 


my  care  in  1 878.  The  swelling  began  nine  years  before,  and 
was  of  the  size  of  an  ordinary  orange,  round,  very  hard,  and 
fixed  to  the  angle  of  the  lower  jaw  on  the  right  side.  Its 
edges  were  well  (hdined,  there  was  no  fluctuation  nor  pulsa- 
tion,' except  that  of  the  facial  artery,  which  was  stretched 


TREATMENT    OF    DENTIGEROUS    CYSTS.  193 

over  the  tumour.  Externally  the  tumour  appeared  to  be 
solid,  but  examined  from  the  mouth,  the  anterior  part  of  the 
wall  yielded  slightly  to  firm  pressure.  On  puncturing  from 
the  mouth  through  the  bony  wall  I  entered  a  large  emfty 
cavity  lined  with  soft  tissue,  which  on  microscopical 
examination  showed  portions  of  hyaline  cartilage  and  carti- 
lage with  a  faintly  fibrous  matrix,  surrounded  by  and 
gradually  passing  into  oval  and  spindle  cells.  The  bony 
walls  of  the  cyst  were  broken  down  and  partially  cut  away, 
and  this  proceeding  was  repeated  a  fortnight  later.  The 
tumour  gradually  diminished  as  suppuration  Avent  on, 
several  pieces  of  bone  being  removed,  and,  six  weeks  after 
the  cyst  had  been  opened,  a  tooth  was  felt  fixed  at  the 
bottom  of  the  cavity,  and  on  being  extracted  proved  to  be  a 
bicuspid  with  a  perfect  crown  and  two  small  fangs.  After 
this  the  cavity  closed  and  the  swelling  entirely  disappeared. 
The  case  is  remarkable,  both  for  the  age  of  the  patient  and 
also  for  the  fact  that  the  cyst  was  empty,  the  fluid  which 
must  have  been  present  at  one  time  having  become  absorbed. 
A  careful  search  for  a  tooth  was  made  at  the  time  of  the 
operation,  but  one  could  not  be  found,  and  its  discovery  at 
a  later  date  was  probably  due  to  the  destruction  by  suppura- 
tion of  the  lining  membrane  of  the  cyst,  which  had  completely 
enveloped  it. 

In  the  Museum  of  the  Eoyal  College  of  Surgeons  is  a 
preparation  (2194)  of  the  right  side  of  the  body  of  the  lower 
jaw,  completely  and  uniformly  dilated  into  a  large  spherical 
cyst.  No  tooth  or  rudiment  of  a  tooth  can  be  discovered 
in  the  cyst,  but  its  inner  surface  is  lined  by  a  layer  of  small 
epithelial  cells  and  is  thrown,  in  places,  into  thick  project- 
ing folds.  Mr.  Eve  considers  it  probable  that  the  cyst 
originated  in  the  enamel-organ  of  an  abortive  wisdom  or 
supernumerary  tooth,  and  hence  would  consider  it  an 
example  of  the  follicular  cyst  developed  in  the  embryonic 
period  (Magitot). 

Treatment. — The  treatment  of  dentigerous  cysts  is  the 
same  as  for  ordinary  cysts — viz.,  a  free  incision ;  and  the 
subsequent  extraction  of  the  contained  tooth.     For  the  cure 

O 


194  DENTIGEROUS    CYSTS. 

of  many  of  these  cases  simple  puncture  will  not  sufiice,  and 
it  will  be  necessary  to  remove  a  portion  of  the  front  wall  of 
the  cyst,  and  to  fill  the  cavity  with  lint  so  as  to  induce 
granulation  and  gradual  obliteration.  This  may  be  accom- 
plished in  most  instances  without  any  incision  of  the  integu- 
ments, and  in  a  few  more  extensive  cases  by  simply  dividing 
the  lip,  and  carrying  the  incision  into  the  nostril. 

In  cases  where  a  permanent  opening  into  the  antrum  is 
not  required,  it  will  be  sufficient  to  turn  up  a  sort  of  trap- 
door, as  suggested   by  0.  Weber,  the  periosteum   serving  as 

Fig.  89. 


the  hinge,  so  that  it  may  be  replaced  after  the  removal  of 
the  contained  cysts.  It  can  but  rarely  happen  that  such  an 
extensive  mutilation  can  be  requisite  as  is  shown  in  a  pre- 
paration in  Guy's  Hospital  Museum  (1087),  consisting  of 
the  outer  wall  of  the  antrum  and  the  palatine  plate,  con- 
taining all  the  teeth  of  the  left  side  except  the  central 
incisor,  which  was  removed  by  Mr.  Key  from  a  case  of  very 
greatly  distended  antrum. 

In  the  case  of  dentigerous  cysts  of  the  lower  jaw  it  will, 
after  removal  of  a  portion  of  the  wall,  be  advisable  to 
squeeze  the  plates   together  as  far  as   possible,  and   in   the 


TREATMENT    OF   DENTIGEROUS    CYSTS.  195 

case  of  the  upper  jaw  pressure  by  pads  and  bandages,  as 
recommended  by  Listen,  will  do  much  to  restore  the  parts 
to  their  usual  form.  Dr.  Forget  relates  the  case  of  a  woman, 
of  about  thirty,  witli  a  hemispherical  tumour  of  the  right 
side  of  the  lower  jaw,  which  was  produced  by  the  bulging 
of  the  external  plate  of  the  ramus  of  the  jaw,  the  internal 
having  preserved  its  usual  position.  M.  Xelaton  exposed 
the  tumour,  and  making  a  hole  in  the  outer  wall  found  a 
tooth  projecting  into  the  cyst.  The  tooth  was  extracted 
with  some  difticulty,  and  the  patient  perfectly  recovered,  and 
was  well  ten  years  after.  The  accompanying  illustration, 
(fig.  89j,  represents  the  relation  of  the  parts,  h  pointing  out 
the  position  of  the  tooth.      {Dental  Ecview,  1860.) 

The  cyst  should  always  be  reached  by  dividing  the  mucous 
membrane  within  the  mouth,  and  without  incising  the  cheek ; 
but  if  necessary,  a  single  line  of  incision  only  should  be  made^ 
so  that  as  little  after-deformity  as  possible  may  be  produced. 


O   2 


196 


CHAPTEE  XIII. 

CYSTS    OF    LOWEE    JAW — MULTILOCULAR    CYSTIC    TUMOUE. 

During  the  last  few  years  very  considerable  light  has  been 
thrown  upon  the  clinical  history  and  pathology  of  certain 
cystic  tumours  of  the  jaws,  both  by  cases  occurring  in  my 
own  practice,  and  by  the  careful  microscopic  investigation  of 
these  and  others  by  Mr.  Erederick  Eve,  who  embodied  his 
results  in  a  lecture  given  at  the  College  of  Surgeons  in  1882, 
and  published  in  the  British  Medical  Journal  of  January  6, 
1883.  Believing  that  Mr.  Eve's  views  are  confirmed  by 
clinical  experience,  I  have  adopted  them  in  the  following- 
pages,  and  shall  include,  under  the  head  of  "  multilocular 
cystic  tumour,"  several  tumours  wliich  in  former  editions  of 
this  work  were  classed  as  "  cystic  sarcoma" — always  an 
unsatisfactory  term — as  well  as  those  hitherto  regarded  as 
simply  multilocular  cysts. 

Mr.  Eve  believes  that  so  far  from  multilocular  cysts  having 
a  dental  origin,  they  are  produced  by  an  ingrowth  of  the 
epithelium  of  the  gum.  They  have  frequently  followed  some 
form  of  injury,  irritation  by  decayed  teeth,  or  long-continued 
inflammation,  which  has  induced  an  increased  supply  of 
blood  to  the  parts.  The  multilocular  cystic  tumours  are 
slow  of  growth,  they  have  very  little  tendency  to  implicate 
surrounding  parts  or  the  neighbouring  lymphatic  glands,  and 
if  completely  removed  rarely  recur  and  still  more  rarely 
become  disseminated  through  the  system.  Their  comparative 
innocence  is  probably  explained  by  the  bony  capsule  forming 
their  boundary,  by  their  low  degree  of  vascularity,  and  by 
the  remarkable  tendency  of  the  ejjithelial  cells  composing 
them  to  undergo  degenerative  changes. 

Multilocular  cysts  may  contain  other  cysts   within  them, 


MULTILOCULAR   CYSTS.  197 

but  this  condition  must  be  a  rare  one,  for  I  can  find  only 
two  examples  of  it.  One  is  a  congenital  cystic  tumour  in 
an  infant  of  six  months,  who  was  under  Mr.  Coote's  care  in 
1861,  and  of  which  the  following  brief  facts  are  extracted 
from  the  Lancet  of  Aug.  31,  1861: — "The  right  half  of 
the  lower  jaw  was  enormously  enlarged,  and  occupied  a 
prominent  position  in  the  neck,  extending  downwards  as  far 
as  the  chest.  It  aj)peared  to  invade  the  entire  bone,  but 
was  really  confined  to  the  right  side.  Its  increase  had  been 
rapid  since  birth,  and  as  it  was  still  enlarging  it  became 
necessary  to  do  something  to  afford  a  chance  for  life,  as,  if 
left  alone,  suffocation  would  have  ensued  in  a  short  time. 
Accordingly,  chloroform  being  given,  an  incision  was  made 
by  Mr.  Coote  upon  its  outer  part,  and  a  thin  shell  of  the 
expanded  jawbone  reached.  This  was  opened,  and  the 
interior  was  found  to  be  filled  with  a  regular  nest  of  cysts, 
one  placed  within  the  other,  all  of  which  were  removed,  and 
the  cavity  closed  with  lint.  Very  little  blood  was  lost 
during  the  operation,  and  for  a  few  days  afterwards  the  child 
improved  very  much  in  health,  although  necessarily  weak, 
and  the  great  swelling  of  the  neck  was  much  diminished. 
Suppuration  became  freely  established,  and  the  drain  shortly 
after  began  to  tell  upon  the  system,  for  the  child  became 
weaker  and  weaker,  although  well  supplied  with  wine  and 
good  nourishment,  and  finally  died  from  exhaustion." 

The  other  instance  is  given  by  Mr.  Syme  {Lancet,  March 
10,  1855),  who  quotes  the  case  of  a  woman  having  a  large 
cystic  tumour  of  the  lower  jaw,  in  whom  he  three  times 
opened  the  cyst  and  stuffed  it,  with  temporary  benefit.  He 
was  obliged  eventually,  however  (five  years  after  the  first 
operation),  to  remove  one-half  of  the  bone,  when  the  cyst 
was  found  to  be  compound,  there  being  four  cavities,  the 
walls  of  which  were  studded  with  smaller  cysts. 

Multilocular  cysts  are  more  often  found  in  the  lower  than 
in  the  upper  jaw,  and  in  most  cases  in  direct  connection 
with  teeth  or  stumps.  In  the  Guys  Hospital  Beports  for 
1847  is  the  notice  of  a  case  of  the  kind  by  Dr.  Wilks,  in  a 
girl"  of  eighteen,  in  whom  there  had  been  an  enlargement  of 


1.98  CYSTS    IN    THE    LOWER   JAW. 

the  right  side  of  the  lower  jaw  for  twelve  years.  The 
tumour,  on  removal,  proved  to  be  a  cystic  growth  :  "  there 
being  four  or  five  large  cells  between  the  internal  and  external 
plates  of  bone,  which  appeared  like  expanded  alveoli,  all  of 
them  containing  fangs  of  teeth.  The  cells  contained  a  glairy 
fluid."  Very  considerable  alteration  in  the  form  of  the 
maxilla  may  be  produced  by  growths  of  this  kind,  of  which 
a  good  example  is  seen  in  the  drawing  (fig.  90)  from  a 
macerated  specimen  in  St.  Bartholomew's  ]\Iuseum  (I.  308.) 

Fig.  90. 


Here  the  bone  is  irregularly  expanded  in  great  part,  to  form 
septa  between  cysts.  These,  which  were  independent  of  one 
another,  had  their  origin  in  the  interior  of  the  bone,  were 
lined  by  a  highly  vascular  membrane,  and  contained  thin 
serous,  or  grumous,  blood-tinged  fluid.  The  walls  of  some  of 
the  cysts  were  thin  and  yielding,  but  others  were  thick  and 
resisting,  and  this  was  particularly  the  case  Mdth  the  most 
posterior  cyst  on  the  left  side,  which  had  pressed  upon  and 
caused  absorption  of  the  left  ramus  and  coronoid  process. 


SKELETON    OF    CYSTS.  199 

The  preparation  was  taken  after  death  from  an  old  man 
aged  seventy-five,  who  had  noticed  the  enlargement  for  five 
years  when  he  came  under  Mr.  Coote's  care  in  St.  Bartho- 
lomew's Hospital  in  1857.  The  following  brief  account  of 
the  case  is  taken  from  the  Lancet  of  Oct.  10,  1857  : — 
"  The  origin  of  the  affection  Mr.  Coote  attributed  to  the 
irritation  produced  by  the  stumps  of  decayed  teeth.  He 
punctured  some  of  these  cysts  with  a  trocar,  and  gave  exit 
to  a  sero-purulent  fluid  from  one,  and  fluid  like  the  white 
of  egg  from  two  others.  On  the  5th  of  September  he  pulled 
( )ut  a  couple  of  bodies  of  teeth,  with  scarcely  any  remains  of 
fangs,  but  in  their  stead  some  irregular  fibrous-like  projec- 
tions. The  removal  of  these  permitted  the  flow  of  a  sero- 
albuminous  fluid,  the  teeth  having  acted  like  stoppers.  Since 
the  man  had  been  in  hospital,  the  size  of  the  tumour  had 
most  certainly  diminished  one-third  under  the  plan  of  treat- 
ment of  puncturing.  The  age  of  the  patient  precluded  the 
possibility  of  attempting  any  more  severe  measures  than 
those  already  adopted.  On  the  21st  the  swelling  had  some- 
what increased,  and  three  or  four  of  the  cysts  were  again 
punctured,  with  the  discharge  of  a  thick,  clear,  yellow  fluid, 
and  several  of  these  were  run  into  one  internally.  This  was 
done  under  partial  anaesthesia  from  chloroform.  One  of  the 
cysts  discharged  a  good  deal  in  the  mouth  ;  this  was  partly 
swallowed,  and  had  caused  indigestion." 

In  St.  Mary's  Hospital  Museum  is  a  valuable  recent 
specimen  (A.  d.  50)  of  the  same  disease,  removed  by  Mr. 
Lane.  Here  the  growth  was  of  seven  years'  duration,  and 
involved  the  left  side  of  the  body  of  the  lower  jaw.  A 
longitudinal  section  shows  the  cystic  structure,  the  cells  of 
which  were  filled  with  dark  gelatinous  fluid,  and  occupied 
the  whole  thickness  of  the  bone. 

The  cells  may,  however,  be  of  much  smaller  size ;  thus 
Dr.  Eobert  Adams  records,  in  the  Duhlin  Hospitcd  Gazette 
for  1857,  the  case  of  a  man  from  whom  he  removed  a  por- 
tion of  the  body  of  the  jaw  from  the  symphysis  to  the  molar 
teeth,  about  two  inches  in  length.  "  The  mucous  membrane 
coyering  it  was  here  and  there  raised  into  small  rounded 


200 


CYSTS    IN    THE    LOWER   JAW. 


eminences  of  the  size  of  peas,  though  some  were  larger  and 
purple  in  colour  (fig.  91).  The  tumour  was  composed  of  bony- 
cells  of  a  texture  as  fine  as  the  ethmoid  bone.  The  cells 
generally  were  of  such  a  size  that  each  might  be  capable  of 
receiving  witliin  it  a  garden  pea.  They  communicated  wii;h 
each  other,  and  amounted  to  no  less  than  twenty-six  in 
number.  They  were  all  lined  by  a  pulpy,  very  red,  vascular 
membrane,  and  contained  an  albuminous  fluid  tinged  of  a 
reddish  colour,  apparently  from  blood  held  dissolved  in  it." 

Fig.  91. 


A,  Canine ;  B,  Second  molar  ;  c,  Anterior  portion  of  dental  nerve ; 
D,  Remains  of  the  base  of  horizontal  branch  of  jaw  excavated  ou  its 
upper  surface,  on  which  lay  the  tumour. 

Again,  in  cases  of  long-standing  disease  the  cysts  become 
greatly  distended,  and  the  septa,  in  great  part,  absorbed,  so 
that  the  cysts  communicate  very  freely. 


MR.    CUSACK'S   case. 


201 


Of  this  kind  was  a  tumour  (fig.  92)  removed  by  Mr.  Cusack, 
in  1826,  from  a  woman  named  Kenny,  whose  case  will  be 
found  in  detail  in  Mr.  Cusack's  well-known  essay  in  the 
Diiblin  Jlosjntcd  Reports,  vol.  iv.  Dr.  Adams,  in  his  paper 
already  referred  to,  supplies  an  account  of  the  tumour  in 
this  case.  "  The  portion  of  bone  removed  comprises  the 
entire  right  half  of  the  lower  jaw.      The  liorizontal  ramus  is 

Fig.  92. 


expanded  into  an  oblong  hollow  shell  with  bony  walls,  and 
its  interior  is  subdivided  into  many  cells  of  various  sizes, 
which  are  all  lined  by  a  fine  polished  membrane,  and  com- 
municate freely  with  each  other." 

The  microscopic  character  of  the  solid  material  found 
more  or  less  in  all  cases  of  multilocular  cyst  is  well  given  in 
the  following  report  by  Mr.  Eve  upon  a  very  well-marked 
recent  specimen  of  the  disease,  contributed  to  the  St.  Bartholo- 


202  MULTILOCULAR    CYSTIC   TUMOUK. 

iiiew's  Hospital  Museum  (1.536)  by  Mr.  Keetley: — "The  solid 
portion  of  the  tumour  was  composed  of  columns  of  cells  and 
nuclei  of  the  epithelial  type,  which,  when  cut  transversely, 
presented  the  appearance  of  alveoli ;  similar  small  columns 
branched  out  from  the  side  of  the  larger.  The  cells  in  the 
centre  of  the  columns  had  in  many  places  undergone  a  colloid 
change,  and  by  the  complete  metamorphosis  of  the  cells  the 
cysts  were  formed.  From  the  buccal  mucous  membrane 
covering  the  tumour,  in  certain  parts,  club-shaped  and  branch- 
ing cylinders  extended  down  from  the  deep  stratmn  of  the 
epithelium,  as  in  the  ordinary  formation  of  epithelial  cancer." 
My.  Eve  has  found  precisely  the  same  characters  in  twelve 
specimens  of  multilocular  cystic  tumours  he  has  examined, 
one  of  the  most  marked  being  a  tumour  of  the  upper  jaw 
removed  by  Mr.  Listen  in  1836,  and  referred  to  in  his  paper 
in  the  Medico- Chirurgical  Transactions^  vol.  xx.,  the  tumour 
being  now  in  the  College  of  Surgeons'  Museum  (2202). 

To  show  the  identity  of  the  foregoing  with  the  tumours 
hitherto  classed  as  "  cystic  sarcomata,"  I  may  quote  the 
description  of  the  microscopic  appearances  of  a  tumour  of 
the  latter  kind  removed  by  myself,  in  1871,  from  a  patient 
jet.  twenty-two,  whose  portrait  before  and  after  the  operation 
is  given  in  figs.  93  and  94,  and  whose  case  will  be  found 
in  detail  in  the  Appendix  (Case  IX.)  : — "  The  timiour  was 
composed  microscopically  of  straight  or  tortuous  columns  of 
epithelial  cells,  those  forming  the  margin  being  elongated  or 
cylindrical  and  radiating  towards  the  centre.  At  the  margin 
of  the  small  ulcerated  opening  in  the  gum,  papillary  processes 
extended  downwards  from  the  deep  stratum  of  the  epithelium, 
and  were  continuous  with  the  columns  forming  the  tumour" 
(College  of  Surgeons'  Museum,  2203).  The  half  of  this 
tumour,  deposited  in  the  Museum  of  University  College,  is 
described  in  tlie  valuable  catalogue  by  Mr.  Marcus  Beck  as  a 
"  gland-like  tumour  of  bone,"  and  its  structure  is  identical 
with  that  of  a  tumour  described  by  Mr.  Wagstafle  in  the 
Fatlwlorjical  Society  s  Transactions,  vol.  xxii.  Mr.  Wagstaffe 
found  that  the  growth  was  composed  of  innumerable  cysts 
and  a  solid  matrix,  through  which  a  certain  amoun<t  of  bone 


CYSTIC   SARCOMA. 


203 


was  scattered  ;  that  the  cysts  were  lined  by  a  layer  of  largo 
globular  epithelium  ;  that  into  the  interior  of  the  larger  cysts 
other  smaller  cysts  projected,  and  these  endogenous  cysts 
took  their  origin  in  the  epithelial  lining,  and  not  in  the 
matrix  of  the  growth.  Other  cysts  were  also  freely  scattered 
throughout  the  structure,  but  the  endogenous  formations 
were  so  marked  that  they  could  be  discovered  as  little  balls 
by  the  naked  eye,  and  removed  for  examinatioifby  the  point 
of  a  needle.     The  solid  structure  consisted  of  a  very  peculiar 


Fi(.'.  03. 


Fig.  94. 


arrangement  of  what  appeared  to  be  acini  or  cylinders  of 
closely-packed  cells,  supported  by  a  fibro-nucleated  matrix. 
These  acini,  or  rods,  in  many  places  gave  the  appearance  of 
tubes  from  the  arrangement  of  their  component  cells,  which 
resembled  very  curiously  that  of  columnar  epi  thelium,  or  of 
the  epithelium  of  gland  follicles.  The  cut  ends,  however, 
showed  no  central  canal.  The  constituents  of  these  rods- 
were  nuclei  embedded  in  plastic  matter,  and  these  separated 


204 


MULTILOCULAR  CYSTIC   TUMOUR. 


by  manipulation  into  small  tailed  or  so-called  spindle  cells, 
of  similar  size  and  character  to  the  corj^iiscles  of  an  ordinary 
sarcoma. 

The  best  example  of  the  disease,  hitherto  Lnowa  as  cystic 

Fic.  95. 


sarcoma,  with  wliich  I  am  acquainted,  is  in  the  Museum  of 
the  Richmond  Hospital,  Dublin,  and  was  removed  by  the 
late  Dr.  Hutton.  It  is  represented  in  the  accompanying 
woodcut  (fig.  95),  for  which  I  am  indebted  to  Dr.  1*.  Adams, 


MULTILOOULAR    CYSTIC  TUxMOUK.  205 

and  sliows  very  beautifully  tlie  development  of  cysts  of 
various  sizes  in  a  growth  of  a  benign  character,  involving 
the  whole  of  one  side  of  the  body  of  the  jaw  and  extending 
to  an  inch  beyond  the  symphysis.  The  patient  was  a  young 
woman  of  twenty,  and  the  tumour  had  existed  nine  years, 
but  had  only  recently  made  rapid  progress,  and  produced 
great  distress  by  its  pressure  on  the  tongue  and  mouth.  Dr. 
Hutton  removed  the  jaw  from  the  right  of  the  symphisis  to 
the  left  angle,  and  the  patient  made  a  good  recovery  (DuUin 
Hosintal  Gazette,  1860).  In  this  case  the  disease  invaded 
only  the  body  of  the  bone,  but  the  ramus  is  also  liable  to  it, 
a  specimen  in  King's  College  Museum,  removed  by  the  late 
Mr.  J.  H.  Green,  being  an  instance  in  point. 

The  contents  of  these  cysts  vary  in  consistency  and  colour  ; 
in  some  cases  being  clear  and  limpid,  in  others  almost 
gelatinous  and  of  a  dark  colour. 

My  attention  was  first  directed  to  the  fact  that  multi- 
locular  cystic  disease  is  not  always  a  simple  local  ailment, 
by  the  case  of  a  patient  who  w^as  able  to  give  me  a  "  Thirty- 
five  years  history  of  a  maxillary  tumour,"  which  I  communi- 
cated in  1880  to  the  Association  of  Surgeons  practising  Dental 
Surgery  {British  Medical  Journal,  May  22,  1880).  The 
patient,  when  he  first  came  under  my  notice  in  1877,  was  a 
healthy  country  gentleman,  who  said  that,  as  long  as  he  could 
remember,  there  had  been  some  enlargement  of  the  right  side 
of  the  lower  jaw.  In  1845  this  enlargement  increased  very 
rapidly,  and  in  1847  Sir  W.  Fergusson  removed  a  tumour 
of  the  right  side,  sawing  through  the  ramus  horizontally,  and 
the  body  of  the  jaw  close  to  the  right  canine  tooth.  The 
tumour  was  apparently  of  a  fibroid  character,  having  a  large 
cyst  developed  in  it,  and  is  now  in  the  Museum  of  King's 
College.  He  continued  in  good  health  for  fifteen  years,  and 
then  noticed  the  formation  of  a  cyst  in  the  incisor  region, 
which  had  frequently  been  tapped  by  Sir  W.  Fergussou. 
In  July,  1877,  I  found  cystic  disease  of  the  left  side  of  the 
body  of  the  jaw  extending  to  the  molar  region,  and  operated 
by  extracting  all  the  teeth,  opening  up  the  cysts  freely,  and 
clearing  out  some  solid  growth  with  the  gouge.      From  this 


20 G  MULTILOCULAR   CYSTIC    TUMOURS. 

the  patient  made  a  good  recovery,  with   considerable   con- 
solidation of  the  bone,  but,  in  the  following  November,  one 
cyst  was  found  to  have  developed  anew  in  the  incisor  region, 
and  this  was  treated  in  a  similar  manner.     A  year  later  a 
fresh  development  of  cysts  had  taken  place  and  the  operation 
was  repeated  with  a  good  result,  so  that  in  February,  1879, 
the  jaw  was   completely  consolidated,  and  the  patient  was 
advised  to  have  some  artificial  teeth  fitted.     In  November, 
1879,  the  patient  reappeared  with  a  large  solid  tumour,  in- 
volving the  left  side  of  the  body  of  the  jaw,  which,  noticed 
first  in  June,  had  grown  rapidly  of  late,  and  now  involved 
the  skin  for  an  area  of  a  square  inch.      On  December  2nd 
I  removed  the  tumour  by  sawing  through  the  bone  immedi- 
ately in  front  of  the  left  masseter,  and  also  removed  a  piece 
of  infiltrated  skin  from  the  left  of  the  median  line.      The 
wound  was  brought  together  with  harelip-pins  and  sutures, 
and  only  one  artery  (facial)   was  ligatured.      The  patient 
made  a  good  recovery,  took  food  with  a  spoon,  and  was  able 
to  talk  intelligibly  after  the  first  week,  although   deprived 
now  of  tlic  entire  body  of  the  jaw.      The  low^er  end  of  tlie 
wound  being  left  open  afforded  a  thorough  drain  for  discharge. 
The  patient  returned  early  in  February,  wdien  the  skin  near 
the  wound  was  found  to  be  increasingly  infiltrated,  and  a 
tumour  of  the  size  of  an  orange  was  found  beneath  the  right 
deltoid.      He  had  strained  the  right  arm  in   getting  into  a 
liip-bath,  but  was  quite  clear  that  the  humerus  had  not  been 
struck.     The  tumour  was  painful,  but  the  bone  was  sound, 
the  head  moving  with  the  shaft.     A  week  later  the  patient 
was  found  to  have  a  tumour  in  the  pelvis,  pressing  upon  the 
rectum,  and  springing  from  the  interior  of  the  right  innomi- 
nate Ijone.      From  tliis  time  he  gradually  lost  strength,  and 
died  at  the  end  of  ]\rarch.   The  second  tumour  was  pronounced 
by  Mr.  Doran  to  be  a  round-celled  sarcoma,  and  the  same 
growth  was  found  in  the  piece  of  skin  wliich  was  removed. 
The  earlier  tumour  appeared  to  be  a  fibroid  or  a  spindle-celled 
sarcoma.     No    post-mortem  examination    of    the    internal 
growths  could  be  obtained. 

Tlie  specimen  is  preserved  in  the  Museum  of  the  College 


MULTILOCULAR  CYSTIC   TUMOUR.  207 

of  Surgeons  (2204),  and  Mr.  Eve's  further  examination  con- 
firms the  fact  tliat  tlie  bulk  of  the  tumour  is  round-celled 
sarcoma,  but  in  addition  the  upper  portion  of  the  tumour 
contains  isolated  masses  composed  of  tortuous  closely- 
crowded  columns  of  small  epithelial  cells. 

The  second  case  bearing  upon  the  same  c^uestion  was  in  a 
woman  of  forty-four,  who   was    admitted    into    University 
College  Hospital,  on  November  3,  1875,  with  the  following 
history  : — About  nine  years  before,  the  patient  first  noticed 
a  lump  of  the  size  of  a  pea  beneath  the  tongue,  on  the  right 
side,  which  gave  her  some  pain,  and  for  which  a  tooth  was 
extracted.     From    that  time   she  had  a  succession   of  ab- 
scesses (?)  in  the  lower  jaw,  some  of  which  discharged  in  the 
mouth,  and  one  externally,  and  for  which  she  had  had  several 
teeth  extracted.     Dr.  Parsons,  of  Dover,  had  sent  her  to  me 
three   years   before^  and  I  then  recommended  her  to  come 
into  the  hospital ;  but   she  declined,  and  went   on  with  a 
steadily  increasing  tumour  of  the  lower  jaw  on  the  right 
side.     About    nine    months    before   admission   the  tumour 
seems  to  have  begun  to  increase  with  some  rapidity,  and 
within  the   last    two  months,   the  following  characteristic 
event  happened.     While  eating,  the  patient  felt  a  sudden 
crack  in  the  lower  jaw,  and  this  occurred  twice  in  the  same 
week  ;  and  upon  each  occasion  she  felt  great  j)aiii  in  the 
floor  of   the  mouth  and  upon  moving  the  tongue.      Upon 
admission  there  was  really  very  little  to  be  seen  externally, 
and  a  photograph  taken  at  the  time  shows  that,  excepting  a 
very  small  projection  beneath  the  skin  in  front  of  the  angle 
of  the  jaw,  there  was  nothing  to  call  attention  to  the  patient's 
face.      On  looking  into  the  mouth,  however,  the  tumour  was 
at  once  obvious,  and  is  seen  in  a  cast  taken  from  the  jaw  at 
that  time  (tig.  96).      The  right  side  of  the  lower  jaw  is  seen 
to   be  greatly  expanded  from  immediately  in  front  of  the 
ramus  to  beyond  the  median  line,  the  tumour  measuring 
two  inches  across  at  the  broadest  part,  and  reaching  under 
the  tongue.     Its  surface  was  lobulated  and  rounded,  firm 
and  osseous  in  the  greater  part,  but  yielding   distinctly  on 
pressure  in  two  or  three  places.     The   mucous  membrane 


208 


TUMOURS    OF    THE    LOWER   JAW. 


was  entire  over  the  tumour,  except  at  one  point  wliere  there 
was  an  opening,  from  wliich  a  discharge  constantly  exuded. 
The  incisor  teeth  of  the  right  side  were  displaced  over  to  the 
opposite  side,  and  were  loose.  The  central  incisor  of  the 
left  side  was  displaced  completely  in  front  of  the  other  teeth. 
The  left  canine  and  bicuspids  were  firmly  fixed.  Notwith- 
standing the  size  of  tlie  tumour,  the  outline  of  the  lower 
border  of  the  jaw  was  scarcely  interfered  with,  the   disease 

Fig.  96. 


being  mainly  confined  to  the  alveolar  portion  of  the  bone ; 
and  I,  therefore,  decided  to  operate  from  within  the  mouth, 
so  as  to  avoid,  if  possible,  all  external  scar. 

On  November  10  tlie  patient  was  put  under  chloroform, 
and,  a  gag  having  been  introdi;ced  on  the  left  side,  I  first 
extracted  the  four  incisors,  and  then  made  a  free  incision 
with  a  stout  scalpel  alf)ng  tlie  upper  surface  of  the  tumour, 
cutting  easily  through  the  thin  Ijone  and  tliick  membrane 
forming  its  upper  wall.  A  quantity  of  dark-coloured  cystic 
fluid  at  once  escaped,  and  I  then  cleared  out  tlie  semi-solid 
contents  with  the  finger  and  Kouge.      The  finger  introduced 


MULTILOCULAR    CYSTIC    TUMOUli. 


209 


into  the  cavity  passed  completely  under  the  canine  and 
bicuspid  teeth  of  the  opposite  side  without  disturbing  them. 
I  next  cut  away  a  portion  of  the  cyst- wall  with  scissors,  and 
crushed  together  the  remainder,  as  far  as  I  could,  with  my 
fingers  and  thumb.  The  actual  cautery  was  applied  to  one 
spouting  vessel  in  the  margin  of  the  alveolus,  and  the  cavity 
was  stuffed  with  lint  dipped  in  a  solution  of  chloride  of  zinc 
(twenty  grains  to  the  ounce). 

The  patient  had  very  little  constitutional  disturbance ;  the 
plugs  were  gradually  removed  from  the  cavity  of  the  jaw, 
which  was  carefully  syringed  out  frequently  with  Condy's 
fluid,  and  soon  began  to  granulate  and  fill  up.  She 
was  discharged  a  month  after  the  operation,  when  the  two 
plates  of  the  lower  jaw  had  come  together,  and  the  cavity 
was  filled  up  almost  completely  by  granulation-tissue,  there 
being  only  a  shallow  cavity  half  an  inch  long  still  to  be 
filled  up  midway  between  the  angle  and  the  symphysis. 

Fig.  97. 


This  patient  again  presented  herself  in  October,  1878,  nearly 
three  years  after  the  first  operation,  with  a  recurrence  of  the 


210 


MULTILOCULAR    CYSTIC   TUMOUR. 


cysts,\vliicli  were  treated  again  by  gouging  and  crushing  in.  In 
August,  1882,  she  again  appeared  with  a  formidable  tumour 
of  the  lower  jaw,  which  had  already  sprouted  through  the 
chin  at  more  tlian  one  point  (fig.  97).  There  could  be  no 
question  now  of  the  necessity  for  excising  the  portion  of 
jaw  involved,  and  this  I  accordingly  did,  removing  from  an 
inch  in  front  of  the  ancle  on  the  left  side  to  the  right  temporo- 
maxillary  articulation.  The  patient  made  a  good  reco^'ery, 
and  lias  remained  well. 

Fio.   98. 


The  occurrence  of  solid  epitlieliomatous  growths,  as  a 
sequel  of  multilocular  cystic  disease,  being  now  sufficiently 
illustrated,  T  may  refer  again  to  the  case  of  "  cystic  sarcoma" 
described  at  p.  202,  and  illustrated  by  figs.  93  and  94.  It  will 
be  found  on  refening  to  the  details  of  the  operation  (Case  IX.), 
that  I  left  in  situ  the  coronoid  process  and  condyle  with 
part  of  the  posterior  border  of  the  lower  jaw,  in  June,  1872. 
In  Octol)er,  1883,  tliis  patient  reappeared  in  the  condition 
sliown  in  fig.  98,  with  a  typical  epitlielial  ulcer  of  the  skin 
of  the  cheek.      On  proceeding  to  cut  this   away   freely,  I 


TREATMENT    OF    CYSTS    IN    LOWER    JAW.         211 

found  that  it  was  attached  to  the  remains  of  the  lower  jaw, 
which  I  was  obliged  to  remove  in  order  to  get  rid  of  the 
whole  of  the  growth.  One  half  of  this  secondary  growth  is 
in  the  Museum  of  the  College  of  Surgeons  (2203A),  and  its 
microscopic  characters  correspond  precisely  to  those  of  the 
former  growth,  p.  202. 

There  can,  then,  I  think,  be  no  doubt  that  under  the  term 
"  multilocular  cystic  epithelial  tumour,"  as  proposed  by  Mr. 
Eve,  we  may  include  the  old  multilocular  cysts  and  cystic 
sarcomata,  both  having  a  distinct  tendency  to  be  reproduced 
locally,  and  in  certain  cases  to  become  disseminated. 

Treatment. — Mr.  Butcher,  of  Dublin,  has  for  some  years 
treated  cases  of  multilocular  cyst  of  the  lower  jaw  through 
the  mouth,  by  dividing  the  mucous  membrane  over  the  cyst 
freely,  and  then  with  gouge  and  bone-forceps  removing  the 
expanded  external  plate  of  the  bone,  with  the  contents  and 
lining  membrane  of  the  cyst.  In  this  operation,  the  teeth 
are  interfered  with  as  little  as  possible,  and  appear  to  remain 
firm.  Granulations  rapidly  spring  up  from  the  denuded 
bone,  and  fill  the  wound  made  in  the  mouth ;  the  cheek 
resumes  its  ordinary  appearance,  and  no  deformity  or  scar  is 
left.  In  his  work  on  "  Operative  and  Conservative  Surgery," 
Mr.  Butcher  narrates  three  cases  treated  in  this  manner, 
and  remarks,  that  "  the  proceeding  according  to  this  plan  is 
troublesome  and  difficult,  but  its  value  to  the  patient  in 
having  no  deformity  left  is  priceless."  A  valuable  caution  is 
here  given  respecting  the  facial  artery,  which  might,  without 
care,  be  divided  from  within  the  mouth  in  a  position  where 
it  would  be  very  difficult  to  secure  it.  Mr.  Butcher  also 
narrates  and  gives  a  drawing  of  a  case  in  which,  finding  the 
disease  too  extensive  to  be  treated  from  the  mouth,  he 
adopted  Dupuytren's  external  incision,  and  then  levelled  the 
projection  to  the  line  of  the  healthy  bone  with  the  best 
results,  the  incision  being  completely  hidden  behind  the 
bone. 

Dr.  Mason  Warren  has  also  {Boston  Medical  and 
Surgical  Journal,  1866)  written  upon  the  treatment  of  cysts 
of   the  jaws,  and  strongly  recommends  a  milder  and  even 

P  2 


212  MULTILOCULAR   CYSTIC   TUMOUR. 

more  conservative  practice  than  tliat  followed  by  Mr. 
Butcher,  which  he  thus  summarizes  : — "  The  treatment  con- 
sisted in  the  puncture  of  the  sac  within  the  mouth,  evacuating 
its  contents,  and  at  the  same  time  obliterating  its  cavity  by 
crusliing  in  its  walls  ;  and  lastly,  in  keeping  up,  by  injec- 
tions, &c.,  a  sufficient  degree  of  irritation  to  favour  the 
deposition  of  new  bone." 

I  have  now  treated  a  considerable  number  of  simple  and 
multilocular  cysts  by  Mr.  Butcher's  method,  and,  as  has  been 
noted,  with  recurrence  in  at  least  two  of  the  latter.  Mr. 
Butcher  does  not  appear  to  have  met  with  further  trouble  in 
his  cases,  and  this  may  depend  upon  his  "  carrying  out  the 
gouging  fearlessly  and  far  wide  of  the  disease."  I  should  in 
future  be  guided  by  the  age  of  the  patient,  and  the  amount 
of  solid  material  found  in  the  cysts.  In  young  persons  with 
cysts  having  fluid  contents  and  little  growth  in  the  bone,  I 
should  be  still  inclined  to  adopt  palliative  measures  and  to 
gouge  very  freely,  carefully  watching  the  case  with  a  view 
to  a  more  radical  proceeding,  should  further  development  take 
place.  In  cases  of  much  solid  deposit  in  connection  with 
multilocular  cysts,  and  still  more  in  cases  of  solid  tumour 
with  one  or  more  large  cysts,  there  should,  I  think,  be  no 
doubt  as  to  the  removal  of  one-half  or  more  of  the  lower 
jaw,  or  of  any  portion  of  the  uj^per  jaw  involved. 

In  his  well-known  essay  on  "Diseases  of  the  Jaw"  (Calcutta, 
1844)  Mr.  O'Shaughnessy  narrates  a  case  of  large  cystic 
disease  of  the  jaw  which  would  appear  to  have  been 
originally  a  multilocular  cyst,  in  which  the  septa  had  under- 
gone almost  complete  absorption,  so  that  "  the  tumour  after 
maceration  was  found  to  be  a  hollow  shell  of  bone,  con- 
taining in  its  centre  a  quantity  of  a  gelatinous  and  fluid 
substance,  and  a  few  particles  of  bone  like  pieces  of  honey- 
comb. The  coronoid  process  was  hollowed  out  like  the  rest 
of  the  bone,  and  so  thick,  that  it  must  have  completely 
filled  the  temporal  fossa,  which  accounts  for  the  difficulty 
experienced  in  trying  to  divide  the  temporal  muscle." 

This  difficulty  of  clearing  the  coronoid  process  has  been 
noticed  also  in  cases  where  the  bone  has  been  expanded  by 


CYSTS    IN  THE    LOWER   JAW.  213 

a  solid  growth  within  it,  or  is  wedged  in  by  a  portion  of 
tumour  springing  from  the  ramus.  Dr.  Eobert  Adams 
narrates  (Dublin  Hosioital  Gazette,  April  15,  1857)  a  case 
of  the  former  kind,  and  Mr.  Cusack  (DuUin  Hosjntal  Reports, 
vol.  iv.)  two  cases  of  the  latter,  in  all  of  which  the  difficulty 
was  overcome  by  sawing  through  the  ramus  of  the  jaw  and 
subsequently  removing  the  coronoid  process  and  condyle. 
The  possible  occurrence  of  this  difficulty  is  to  be  borne  in 
mind  in  cases  of  cystic  growth  requiring  disarticulation ; 
and  I  experienced  it  in  tlie  case  of  large  "  cystic-sarcoma," 
already  referred  to. 

The  difficulty  is  best  got  over  by  the  division  of  the 
coronoid  process  with  the  Ijone-forceps,  and  the  piece  thus 
cut  off  should  afterwards  be  dissected  out. 


214 


CHAPTEE  XIV. 

TUMOURS    CONNECTED    WITH    TEETH    AND    ODONTOMATA. 

Irregular  development  of  the  teeth  is  of  little  interest  from 
a  surgical  point  of  view,  except  when,  from  their  abnormal 
positions,  they  give  rise  to  tumours  of  the  jaw.  The  rela- 
tion of  cysts  to  undeveloped  teeth  has  been  discussed  under 
the  head  of  "  Dentigerous  Cysts,"  but  the  solid  growths 
directly  connected  with  the  teeth  also  require  investigation. 

The  irregularities  of  the  teeth  which  are  fully  cut  come  into 
the  province  of  the  dental  surgeon,  and  in  Mr.  Tomes' 
valuable  work  on  Dental  Surgery,  numerous  drawings  are 
given  of  the  abnormal  positions  in  which  various  teeth  have 
appeared.  It  is  tlie  uncut  teeth,  however,  which  are  of 
interest  surgically,  and  these  may  be  divided  into  two 
classes.  In  the  first,  the  tooth  which  has  deviated  from  its 
normal  position  is  still  contained  within  the  alveolus,  where 
by  its  presence  it  may  give  rise  to  a  more  or  less  distinct 
tumour.  Of  this  tig.  99  gives  an  example  from  the  work 
of  Dr.  Forget,  on  Dental  Anomalies,  for  permission  to  use 
which  I  am  indebted  to  Mr.  E.  T.  Hulme,  tlie  translator  of 
Dr.  Forget's  papers  in  tlie  Dental  llcvieiv  of  1860.  In  the 
second  class  of  cases  the  misplaced  tooth  is  situated  in  a  part 
of  the  jaw  more  or  less  distant  from  the  alveolus,  and  of  this 
fig.  100  presents  an  example,  the  canine  tooth  being  placed 
horizontally  in  the  floor  of  the  nasal  fossa,  in  the  interior  of 
which  it  formed  a  considerable  projection. 

The  molar  teeth  of  the  upper  jaw,  and  particularly  the 
wisdom  teeth,  seem  especially  liable  to  misplacement.  Mr. 
Tomes  {op.  cit.)  gives  numerous  illustrations  of  tliis  irre- 
;,mlarity,  and  in  the  Museum  of  the   College  of  Suicgeons  is 


MISPLACED   TEETH. 


215 


a  cast  of  a  case  in  wliicli  a  wisdom  tooth  projected  through 
the  clieek.     The  wisdom  teeth  of   the   lower  jaw  arc  also 


Fig.  99. 


prone  to  assume  an  abnormal  position   in  relation  to    the 
coronoid  process,  and  in   either   position  a  tumour   may  be 

Fig.  100. 


216         TUMOURS  CONNECTED  WITH  THE  TEETH. 

formed  which  may  be  difficult  of  diagnosis.  Dr.  Forget 
{op.  cit.)  quotes  the  case  of  a  woman  who  had^  on  the  left 
side  of  the  hard  palate,  a  tumour  of  the  form  and  size  of 
a  nut,  which  reached  beyond  the  median  line,  and  extended 
from  the  canine  tooth  to  the  soft  palate.  Blandin,  on  at- 
tempting to  remove  it,  discovered  it  to  be  caused  by  two 
dwarfed  and  abnormally-placed  molar  teeth,  which  had  pene- 
trated the  inner  plate  of  the  alveolus,  and  were  lodged  be- 
neath the  mucous  membrane  of  the  palate.  On  the  removal 
of  these  the  tumour  subsided.  A  similar  case  of  tumour  of 
the  palate,  due  to  a  molar  tooth,  is  recorded  in  Tomes'  "  Dental 
Surgery."  Still  more  remarkable  is  the  case  narrated  by 
Mr.  Tellander,  of  Stockholm,  before  the  Odontological  Society, 
in  December,  1862,  of  supernumerary .  teeth  imbedded  in 
the  upper  jaw,  causing  a  hard  painless  tumour,  which 
appeared  about  the  age  of  twelve  ;  and  this  again  is  eclipsed 
by  the  case  recorded  by  Mr.  Tomes,  which  occurred  in  the 
person  of  a  Hindoo,  aged  twenty-hve,  who  suffered  from  a 
large  tumour  of  the  front  of  the  upper  jaw.  Mr.  Mathias, 
under  whose  care  the  man  was,  removed  fifteen  masses  of  ill- 
formed  and  supernumerary  teeth  ("Dental  Surgery,"  2nd  ed.). 
It  is  possible,  however,  that  both  these  last  cases  may  have 
been  examples  of  dentigerous  cyst  which  had  ruptured  before 
the  patient  came  under  observation,  resembling  the  case  of 
cyst  with  nodules  of  dentine  mentioned  at  page  185. 

The  crown  of  a  temporary  tooth,  of  which  the  fang  has  been 
absorbed,  may  be  so  crowded  in  by  its  permanent  neighbours 
as  to  disappear  witliin  the  alveolus  and  give  rise  to  irritation 
and  anomalous  symptoms.  1  was  once  consulted  in  a  case 
of  this  kind,  when  Mr.  Edgelow  skilfully  extracted  from 
some  depth  the  temporary  crown,  which  proved  to  contain 
a  stopping ! 

But  the  malposition  of  a  tooth  may  give  rise  to  a  dense 
osseous  tumour  of  the  upper  jaw,  in  which  it  is  impossible  to 
recognize  the  source  of  mischief  until  after  removal  of  the 
tumour.  Of  this  kind  was  a  case  which  occurred  to  Sir 
William  Fergusson,  in  1856,  in  a  girl  aged  thirteen,  in 
whom   for  three    years  there    had  been    growing  a    dense 


ODONTOMATA.  217 

tumour  of  the  left  superior  maxilla,  which,  upon  section 
after  removal,  proved  to  contain  a  tooth  imbedded  in  its 
centre. 

Even  more  remarkable,  however,  than  mere  malposition, 
are  certain  modifications  which  the  molar  teeth  occasionally 
undergo  during  their  development,  giving  rise  to  most 
interesting  tumours  of  the  jaw,  which  have  been  specially 
studied  and  described  under  the  name  Odontomes  by  M. 
Broca  ("  Traite  des  Tumeurs,"  1869).  These  tumours  depend 
upon  some  modification  of  the  germ  of  the  tooth  before  the 
formation  of  the  cap  of  dentine,  and  belong  to  Broca's  second 
class,  odontomes  odonto-plastiqiies  or  odontomes  hidhaires. 
The  result  is  the  formation  of  an  irregular  mass  of  dental 
tissues  in  no  way  resembling  a  tooth  in  shape. 

There  are,  I  believe,  but  eight  cases  of  this  form  of 
odontoma  recorded,  and  these  all  occurred  in  the  lower  jaw. 
The  first  case  was  communicated  to  the  Faculty  of  Medicine 
of  Paris  in  1809  by  M.  Oudet.  The  patient,  a  man  aged 
twenty-five,  had  on  the  right  side  of  the  lower  jaw  a  mass 
occupying  the  position  of  tlie  premolar  teeth,  which  on 
removal  proved  to  be  composed  of  dentine  and  enamel. 
A  similar  mass  on  the  left  side  was  not  removed.  The 
second  case  occurred  some  years  back,  in  the  practice  of 
Sir  William  Fergusson,  by  whom  the  tumour  was  removed 
with  a  portion  of  the  jaw,  and  is  described  by  Mr.  Tomes 
("  Dental  Surgery"),  from  whose  work  a  drawing  of  a  section 
of  the  tumour  is  taken  (fig.  101).  "  The  second  molar  of 
the  lower  jaw  was  represented  by  an  irregularly  flattened 
mass,  composed  of  enamel,  dentine,  and  bone  derived  from 
calcification  of  remnants  of  the  dentine  pulp,  thrown  together 
without  any  definite  arrangement,  by  which  the  wisdom 
tooth  was  held  down.  The  dental  mass,  when  removed 
from  its  receptacle  in  the  bone,  presented  no  resemblance  to 
a  tooth.  Little  beads  of  enamel  here  and  there  projected 
from  the  surface,  which  was  generally  rough  and  irregular. 
The  naked- eye  appearance  of  the  section  is  accurately  given 
in  the  woodcut,  the  radiate  character  in  which  shows  the 
arrangement  of  the  component  tissues,  which,  by  the  aid  of 


218  ODONTOMATA. 

tlie  microscope,  are  seen  at  places  to  alternate.  The 
alternation  is  mainly  eftected  by  the  dentine  and  bony  tissue, 

and  these,  indeed,  form   the  great  bulk  of   the  mass 

The  appearances  presented,  prior  to  the  operation,  consisted 
in  enlargement  of  the  jaw  posterior  to  the  first  permanent 
molar  tooth,  with  a  hard,  brown-looking  body  projecting  but 
slightly  from  the  surface  of  the  gum.  This  projecting 
portion  was,  in  fact,  the  upper  surface  of  the  aberrant  tooth  ; 
and  the  nodules  of  enamel  were,  for  the  most  part,  situated 
in  this  part  of  the  mass. 

The   third   case   occurred  to  Dr.    Forget  {op.  cit.),  in  the 
person  of  a  young  man,  aged  twenty,  who  presented  himself 

Fig.  101. 


in  1855  with  a  disease  of  tlie  lower  jaw,  from  which  he  had 
suftered  since  lie  was  five  years  old.  Upon  looking  into  the 
mouth,  a  round,  smooth  tumour,  hard  and  unyielding,  was 
seen  occupying  nearly  the  whole  of  the  left  side  of  the  jaw. 
None  of  the  teeth  beyond  the  first  bicuspid  were  present.  Dr. 
Forget  removed  the  portion  of  the  jaw  involved  by  sawing 
through  it  in  front  of  the  bicuspid  tooth,  and  also  through 
the  ramus  at  tlie  level  of  the  inferior  dental  foramen.  The 
portion  removed  is  seen  in  tlie  accompanying  drawing  (fig. 
102).  An  examination  of  tlie  portion  which  had  been  re- 
moved, showed  that  the  portion  of  the  jaw  between  the 
ramus  and  the  first  bicuspid  tootli  was  converted  intb  a  cavity. 


ODONTOMATA. 


219 


wliich  was  occupied  by  a  hard  oval  mass,  of  the  size  of  an 
egg,  having  an  uneven  surface  covered  liere  and  there  with 
minute  tubercles,  which  were  invested  by  a  layer  of  enamel, 
penetrating  into  the  substance  of  the  bone,  and  easily  recog- 
nizable by  its  shining  appearance  and  peculiar  colour.  A 
section  of  the  tumour  showed  that  it  consisted  of  a  compact 
tissue  of  tlie  consistence  of  ivory,  of  a  greyish-white  colour, 
in  the  interior  of  which  it  was  possible  to  perceive,  with  the 
naked  eye,  a  kind  of  regular  arrangement  of  the  elements 
whicli  entered  into  its  composition.  Between  the  tumour 
and  tlie  osseous  cyst  was  a  thick  membrane,  apparently  of  a 

Fig.  102. 


fibro-cellular  structure.  At  the  anterior  extremity  of  the 
base  of  the  tumour  was  a  depression  in  which  the  crown  of 
an  inverted  molar  tooth  was  wedged  in  between  it  and  the 
maxilla.  This  tooth  is  seen  in  fig.  102,  c,  where  a  portion  of 
bone  has  been  cut  away;  a  and  h  mark  portions  of  the 
tumour  projecting  through  the  jaw,  and  d  is  the  second  bicus- 
pid tooth  lying  below  the  first,  e. 

The  mi(jroscopic  examination  of  the  tumour  showed  it  to 
be  composed  principally  of  dentine,  with  enamel  on  the  sur- 
face and  dipping  into  the  crevices,  at  tlie  bottom  of  whicli, 
as  Avell  as  in  other   parts,  portions  of  cementum  were  found. 


220  ODONTOMA  TA. 

Dr.  Forget  regards  the  case  as  one  of  fusion  and  hypertrophy 
of  the  last  two  molars. 

The  fourth  case  of  the  kind  was  brought  under  the  notice 
of  the  Odontological  Society  of  Great  Britain,  in  December, 
1862,  by  the  late  Mr.  W.  A.  Harrison,  F.E.C.S.  The 
specimen  closely  resembled  those  already  described,  and 
came  from  the  left  side  of  the  lower  jaw  of  a  lunatic,  where 
it  occupied  the  space  between  the  incisor  and  molar  teeth. 
It  came  away  sj)ontaneously,  leaving  a  long  deep  groove, 
large  enough  to  receive  the  last  joint  of  the  thumb,  which 
soon  granulated  and  contracted.  The  specimen  is  in  the 
Museum  of  the  Dental  Hospital,  Leicester  Square.  Cases 
of  a  similar  kind  have  been  met  with  in  the  lower  animals, 
especially  the  horse.  {British  Journal  of  Dental  Science, 
December,  1862). 

The  fifth  case  is  given  in  Heider  and  Wedl's  Atlas  zur 
Pathologic  der  Zcihnc,  and  closely  resembles  Mr.  Tomes'  case, 
the  second  molar  tooth  of  the  right  side  being  developed 
into  a  large  irregular  mass,  and  holding  down  the  wisdom 
tooth.     It  was  easily  removed. 

Mr.  Annandale  has  reported  {Edinburgh  Medical  Journal, 
Jan.  1873)  a  sixth  case  occurring  in  the  lower  jaw  of  a  young 
woman,  aged  seventeen,  who  had  never  had  any  molar  teeth 
on  the  left  side.  A  nodulated  mass,  which  somewhat  re- 
sembled a  piece  of  necrosed  bone,  projected  above  the  gum, 
and  was  firmly  fixed.  Mr.  Annandale  dislodged  the  growth 
and  removed  it  through  the  moiith.  It  measured  1^  by  \\ 
inches,  and  weighed  300  grains,  and  on  section  showed  "  that 
a  cap  of  enamel,  varying  in  thickness,  was  arranged  over  a 
portion  of  the  irregular  surface  of  the  mass.  Beneath  this, 
well-formed  dentine,  forming  a  considerable  thickness,  was 
met  with  ;  and  still  deeper  in  the  substance  of  the  mass,  true 
bone,  containing  lacuna-,  canaliculi,  and  Haversian  canals, 
was  seen  to  be  intermingled  in  a  confused  manner  with 
portions  of  dentine,  so  as  to  form  the  substance  called  by 
histologists  "  osteo-dentine." 

The  seventh  case  occurred  in  the  practice  of  Dr.  Good- 
willie,  of  New  York,  and  is  mentioned  in  Agnew's  "Surgery/' 


author's  case.  221 

vol.  ii.  It  appeal's  to  have  been  removed  with  the  angle  of 
the  jaw. 

An  eighth  case  has  been  recorded  by  myself  in  the  Clinical 
Sondjfs  Transactions,  vol.  xv.  All  these  specimens  were 
met  with  in  young  adults,  and  only  the  first,  fifth,  sixth, 
and  eighth  were  extracted  from  the  jaw  by  the  surgeon,  in 
Mr.  Harrison's  case  the  mass  coming  away  spontaneously, 
and  in  Mr.  Tomes'  and  M.  Forget's  cases  a  considerable 
portion  of  the  lower  jaw  being  removed  by  such  experienced 
surgeons  as  Sir  William  Fergusson  and  M.  Maisonneuve. 
In  my  own  case  I  must  confess  that  I  did  not  appreciate  at 
first  the  nature  of  the  tumour,  and  recommended  removal  of 
a  portion  of  the  jaw,  and  that  it  was  only  during  a  subse- 
quent operation  undertaken  for  supposed  necrosis  that  the 
true  nature  of  the  case  became  apparent. 

Miss  C.,aged  eighteen, the  daughter  of  a  dental  surgeon,  was 
brought  to  me  in  July,  1881,  w^ith  a  considerable  swelling  of 
the  right  side  of  the  lower  jaw,  some  of  which  was  evidently 
inflammatory,  and  partly  the  result  of  previous  treatment ; 
but  there  "was,  I  thought,  sufficient  evidence  of  expansion  of 
the  jaw  to  warrant  the  opinion  that  a  tumour  was  present, 
and  I  therefore  recommended  the  removal  of  a  portion  of  the 
jaw.  Suppuration  was  then  present,  and  with  the  finger  a 
rough  surface  of  apparently  exposed  bone  could  be  felt,  but 
this  I  regarded  as  the  result  of  inflammatory  action  excited 
by  the  injudicious  irritation  of  a  periosteal  growth,  since 
partial  necrosis  of  a  jaw  involved  by  cartilaginous  or  malig- 
nant growths,  which  have  been  irritated  by  exploratory 
measures,  is  in  my  experience  by  no  means  uncommon.  The 
patient  had  the  advantage  of  the  opinion  of  Sir  James  Paget, 
who  was  not  perfectly  satisfied  as  to  the  existence  of  a  tumour, 
and  expressed  a  hope  that  the  case  might  prove  to  be  one  of 
necrosis.  Under  these  circumstances  the  operation  was 
postponed. 

On  my  return  to  town  in  September  I  found  the  patient 
improved  in  health  and  the  swelling  diminished  by  the  sub- 
sidence of  the  inflammation,  but  a  considerable  enlargement 
of  the  lower  jaw  still  present,  with  a  sinus  opening  externally. 


222 


ODONTOMATA. 


From  the  inoutli  a  white  mass  was  visible,  which,  appearing- 
among  granulations,  looked  like  necrosis,  and  I  agreed  that 
an  attempt  should  he  made  to  remove  this,  although  I  could 
not  thiidc  it  accounted  for  the  expansion  of  the  jaw.  On 
.September  8,  with  the  assistance  of  Dr.  Snow,  the  i^atient 
was  put  under  chloroform,  and  I  proceeded  to  examine  the 
mouth  with  my  finger.  I  soon  found  that  the  white  mass 
was  not  bone  but  tooth,  and  yet  was  unable  to  make  out 
its  outline.  I  was  unable  to  make  any  impression  with  a 
chisel  or  gouge,  lait  at  last  with  an  elevator  succeeded  in 
lifting  out  of  its  bed  a  mass  of  dental  structures,  forming  the 
odontoma  shown  in  figs.  103  and  104. 


Fk;.  103. 


Fi(i.  104. 


The  mass  measured  1^  inches  antero-posteriorly,  1  incli 
transversely,  and  1|  inches  from  above  downwards.  It 
weighed  315  grains  =  ^v.  gr.  xv. 

A  section  of  the  odontoma  lias  been  made,  and  it  has  been 
submitted  to  Mr.  Charles  Tomes,  wlio  has  kindly  furnished 
the  following  re])ort : — 

"  Tlie  wht.)le  surface  of  the  odontoma  is  nodulated  and 
roughened  by  stalactitic  excrescences,  and  there  is  at  no 
point  any  form  recalling  the  character  of  a  tooth  crown. 

"  Tlie  surface  of  a  section  presents  a  complicated  marbled 
pattern,  due  to  the  admixture  of  several  dental  tissues,  and 
it  bears  a  general  resemblance  to  that  form  of  dentine  known 
as  '  plici-dentine,'  or  '  labyrintho-dentine.'  On  the  wliole 
the  mass  is  of  tolerably  uniform  structure  throughout,  though 
there  is  an  area  of  somewhat  simpler  structure  in  its  upper 


ODONTOMATA.  223 

and  central  portion,  from  which  fokls  of  dentine  appear  to 
radiate.  So  far  as  it  goes,  this  would  seem  to  point  to  the 
whole  mass  being  the  product  of  a  single  tooth  germ  rather 
than  of  several  fused  together,  a  matter  which  was  left  in 
some  doubt  by  the  absence  of  an  accurate  history  of  the 
case. 

"  The  excrescences  of  the  surface,  as  well  as  the  greater 
part  of  the  interior,  are  made  up  of  folds  of  dentine,  in  which 
dentinal  tubes  are  very  abundant,  and  which  surround 
flattened  remnants  of  pulp  chambers ;  between  and  intimately 
blended  with  this  comparatively  well-formed  dentine,  is  a 
more  coarsely  calcified  material,  containing  numerous  lacunte, 
and  permeated  by  vascular  channels — in  fact,  osteo-dentine. 

"Enamel  is  present  upon  some  of  the  nodules  of  the 
surface,  but  it  does  not  by  any  means  form  a  complete  in- 
vestment ;  where  present  it  dips  in  folds,  following  the 
convolutions  of  the  dentine,  and  it  is  to  be  met  with  in  the 
very  centre  of  the  mass,  though  not  very  abundantly.  It  is 
nowhere  well  formed,  being  brownish  and  opaque. 

"  This  odontoma  is  the  product  of  the  formative  dentine 
pulp  of  a  tooth  (or  teeth)  which  has,  in  place  of  remaining 
simple,  budded  out  innumerable  processes  on  all  sides,  and 
finally  has  calcified ;  its  enamel  pulp  has  in  parts  followed 
the  complexities  of  its  surface,  and  in  parts  failed  to  do  so, 
or,  at  all  events,  has  failed  to  perpetuate  itself  by  calcifica- 
tion." 

Another  form  of  tumour  connected  with  a  tooth  con- 
sists in  an  outgrowth  from  a  more  or  less  perfect  tooth,  de- 
pending upon  some  modification  of  the  dentinal  pulp,  after  the 
formation  of  the  dentinal  cap.  These  growths  belong  to  the 
Odontomes  coronaires  of  Broca,  and  have  been  described  as 
taartij  teeth  by  Salter.  The  smaller  warty  teeth  hav^  no 
special  surgical  interest,  but  occasionally  the  outgrowth  takes 
place  after  the  completion  of  the  crown  of  the  tooth,  and 
is  large  enough  to  form  a  tumour  requiring  surgical  inter- 
ference. The  rare  examples  of  tliis  form  the  class  Odontomes 
radicidaires  of  Broca.  A  remarkable  specimen  of  the  land, 
in  the  Museum    of   the   Colleo-e    of   Suro-eons  of    England 


224 


ODONTOMATA. 


(2168),  has  been  especially  investigated  by  Mr.  Salter  {Guy's 
Hospital  Reports,  1869),  who  believes  that  the  outgrowtli 
is  due  to  "  hypertrophy  and  dilatation  of  a  fang,  and 
not,  as  was  formerly  supposed,  to  hypertrophy  of  the 
cementum.      Fig  105,  from  Mr.  Salter's  paper,  illustrates  the 

Fig.  105. 


structure  of  the  tumour,  and  fig.  106  shows  the  relation  of  the 
growtli  to  the  tootli.       Tlio    outer    layer    is    composed  of 

Fid.  106.  Fio.  )07. 


cementum,  or  tooth-bone,  and  within  this  is  a  layer  of  true 
dentine,  which  is  wanting  below  ;  and  within  this  again  is  the 


ODONTOMATA.  225 

"  nucleus"  of  calcified  tooth-pulp.  This  last  is  "  composed  of 
a  confused  mass  of  bone- structure  and  dentine- structure, 
arranged  around  and  separating  an  elaborate  vascular  net- 
work of  the  same  character  as  that  of  the  dentinal  pulp." 

Almost  synchronously  with,  but  independently  of,  Salter, 
Professors  Heider  and  Wedl  (Atlas  zur  Pcdhologie  der 
Zclhne)  described  a  tooth-tumour  resembling  in  many  respects 
that  at  the  College  of  Surgeons. 

A  still  larger  specimen  in  connection  with  the  side  of  a 
molar  tooth  is  given  in  fig.  107,  from  a  case  recorded  by  Dr. 
Forget  (op.  cit.).  It  occurred  in  the  practice  of  M.  Maison- 
neuve,  and  in  the  person  of  a  man  aged  forty.  The  tumour 
occupied  the  left  side  of  the  lower  jaw,  causing  both  its 
surfaces  to  project,  but  especially  the  outer.  At  the  smaller 
end  of  the  tumour  was  a  decayed  molar  tooth,  and  upon 
extracting  this  the  tumour  came  away  with  it.  The  growth, 
which  was  larger  than  a  pigeon's  egg,  was  attached  to  the 
tooth  by  a  kind  of  pedicle,  a  section  showing  a  line  of 
separation  between  it  and  the  root  of  the  tooth.  Under  the 
microscope  the  specimen  was  seen  to  contain  no  dentine, 
but  to  consist  exclusively  of  osseous  tissue. 

In  April,  1863,  Mr.  Tomes  exhibited  to  the  Odontological 
Society  an  extraordinary  specimen  of  so-called  exostosis, 
shown  in  the  illustration  (fig.  108),  which  I  have  been  per- 

FiG.  108. 


mitted  to  borrow  from  the  Transactions  of  the  Udontological 
Society  (vol.  iii.).  The  molar  tooth,  to  which  it  is  attached, 
was  removed  by  Mr.  Hare,  of  Limerick,  from  the  upper  jaw 
of  a  man  aged  forty-one,  who  had  long  suffered  pain  in  the 
jaw,  from  which  a  fistulous  passage  led  through  the  cheek. 
-  The  srowth  is  more  or  less  hollowed  out,  and  on  this  account 

Q 


226  ODONTOMATA. 

it  has  been  suggested  that  it  may  possibly  be  an  instance  of 
calcified  dental  cyst.  The  specimen  has,  however,  recently 
undergone  careful  microscopic  examination  by  Mr.  Charles 
Tomes,  who  found  that  it  closely  resembled  Forget's  specimen 
already  described  (fig,  107),  of  which  a  microscopic  section 
is  given  by  Broca.  Mr.  C.  Tomes  brought  the  preparation 
before  the  Odontological  Society  in  January,  1872,  and  has 
shown  that  the  outgrowth  is  not  connected  with  the  fangs 
of  the  tooth,  but  had  sprung  from  the  dentinal  pulp.  This 
latter  he  believes  to  have  undergone  partial  destruction 
before  becoming  calcified,  and  hence  the  cavity  formed  in 
the  tumour.  {Transactions  of  the  Odontological  Society  of 
Great  Britain,  Jan.  1872.)  Whatever  its  nature,  it  must, 
from  its  size,  have  either  invaded  or  obliterated  the  antrum. 
It  will  be  obvious,  from  a  consideration  of  the  preceding 
cases,  that  every  effort  should  be  made  to  extract  an  odontoma 
from  the  jaw  without  removing  any  portion  of  the  bone  itself. 
In  the  case  recorded  by  Mr.  Harrison,  the  tumour  was 
enucleated  spontaneously,  in  four  cases  it  was  removed 
without  difficulty,  and  in  two  other  cases  its  removal  was 
readily  effected  after  the  containing  portion  of  jaw  had  been 
excised.  Where  the  growth  is  presumably  connected  with 
a  tooth,  the  rule  of  removing  all  neighbouring  teeth  which 
may  possibly  l)e  connected  with  it,  sliould  be  invariably 
followed  before  any  more  serious  operation  is  undertaken. 


227 


CHAPTER  XV. 

DISEASES    OF    THE   GUMS. — EPULIS. 

Hypertrophy  of  the  Grums  is  a  by  no  means  common  affec- 
tion. Mr.  Salter  has  recorded  ("  System  of  Surgery,"  ii.)  a  re- 
markable case  which  occurred  in  St.  George's  Hospital  in 
1859,  in  a  girl  of  eiglit  years,  in  whom  there  was  precocious 
development  of  the  teeth,  accompanied  by  hypertrophy  of  the 
gums.  A  large,  pink,  smooth  mass  projected  from  the  mouth,, 
slightly  corrugated  or  indistinctly  lobed,  which  consisted 
of  an  expansion  of  the  alveolus,  immense  hypertrophy  of  the 
fibrous  gum,  and  an  exuberant  growth  of  the  papilla3  of  the 
mucous  membrane.  Dr.  Gross  has  narrated  a  very  similar 
case  in  his  "  System  of  Surgery"  (1862).  In  April,  1867,  I 
had  the  opportunity  of  seeing  a  case  of  the  kind,  under  the 
care  of  Mr,  Erichsen,  in  University  College  Hospital.  A  child 
of  two  and  a  half  years  had  hypertrophy  of  the  gums,  which 
were  prolonged  in  front  of  and  behind  tlie  teeth  so  as  almost 
to  conceal  them.  The  disease  affected  only  the  incisive  por- 
tions of  both  jaws,  and  it  was  remarkable  that  the  temporary 
teeth  had  undergone  hypertrophy  also,  being  considerably 
larger  than  normal.  The  affection  first  showed  itself  at  the 
age  of  seven  months,  wlien  the  teeth  began  to  appear,  the 
gums  increasing  in  size  and  bleeding  on  the  least  touch.  Mr, 
Erichsen  removed  the  exuberant  growth,  extracting  some  of 
the  teeth,  and  freely  cauterized  the  cut  surfaces.  In  Mr, 
Salter's  case  it  was  necessary  to  clip  away  portions  of  the 
alveolus  as  well.  The  excised  portions  in  Mr.  Erichsen's 
case  were  examined  by  the  late  Mr.  A.  Bruce,  who  gave 
the  following  report  upon  them  : — "  On  section  the  mass  was 
found  to  consist  of  a  firm  fibrous  stroma,  containing  much 

Q  2 


228  DISEASES    OF   THE    GUMS. 

glandular  tissue  in  its  interstices,  and  covered  on  its  surface 
by  very  large  and  vascular  papilla3.  The  epithelial  layer  was 
of  unusual  thickness,  but  no  abnormal  epithelial  structures 
were  found  in  the  growth,  which  was  an  example  of  true 
hypertropliy."  These  characters  agree  closely  with  those 
observed  by  Mr.  Salter,  and  it  may  be  remarked  that  though 
in  his  case  the  temporary  teeth  do  not  appear  to  have  been 
hypertrophied,  yet  that  the  permanent  teeth  exposed  in  the 
alveoli  by  the  operation  were  excessively  large,  especially  the 
superior  central  incisors.  I  am  able  now  to  supplement  my 
report  of  Mr.  Erichsen's  patient  operated  upon  in  1867  when 
2J  years  old,  from  the  Medico- Chirurgical  Transactions,  vol.  Ivi., 
to  which  the  late  Dr.  John  Murray,  of  tlie  Middlesex  Hospital, 
contributed  a  paper  "  On  three  Peculiar  Cases  of  Mol]iiscum 
Fibrosum  in  Children  of  one  Family ."  The  eldest  of  these 
was  Mr.  Erichsen's  patient,  now  seven  years  of  age,  and  she 
presented  peculiarities  of  the  skin,  subcutaneous  connective 
tissue,  periosteum  and  ends  of  the  lingers  and  toes.  Dr. 
Murray's  description  of  the  oral  cavity,  is  as  follows  : — "  The 
appearance  of  the  gums  is  very  remarkable.  They  are  every- 
where greatly  hypertrophied,  and  they  almost  completely 
bury  the  teeth.  They  form  in  parts  numerous  papillomatous 
or  polypoid-looking  growths,  and  in  other  situations  present 
a  peculiar  fungating  appearance,  indeed  this  latter  charac- 
teristic of  the  growth  is  at  once  observed.  The  teeth, 
although  almost  buried  by  the  hypertrophied  gum,  are  still 
in  every  case  visible,  and  are,  in  some  measure,  serviceable 
for  the  purposes  of  mastication.  The  enlargement  of  the 
gums  is  most  marked  at  their  upper  and  free  surface,  where 
they  are  mostly  flattened  out  and  in  parts  hardened  by  the 
pressure  of  the  opposing  gum.  They  present  the  natural 
colour,  and  althougli  they  are  in  parts  somewhat  soft, 
vascular,  and  spongy-looking,  they  mostly  feel  lirm  and 
fibrous  to  the  touch,  the  disease  being  distinctly  limited  to 
the  gums." 

The  patient's  brother,  aged  four,  in  whom  the  growth  was 
first  observed  when  he  was  three  months  old,  and  her  sister, 
aged  two,  have  a  similar  condition  of  the  gums. 


HYPERTROPHY    OF    GUMS.  229 

It  is  remarkable  that  in  all  cases  recorded  there  was  a 
defective  mental  condition,  and  the  hypertrophy  of  the  gums 
had  been  noticed  quite  early  in  life,  and  seemed  to  have  been 
general,  affecting  equally  both  jaws,  and  the  whole  extent  of 
the  alveolar  arch,  A  case  of  hypertrophy  of  the  gums, 
in  a  woman  aged  twenty-seven,  was  published  by  Dr. 
Waterman,  of  Boston  {Boston  Medical  and  Surgical  Journal, 
April  8,  1869)  ;  but  the  most  remarkable  instance  of  the 
disease  on  record,  also  occurring  in  the  adult,  is  given  in  the 
Austrcdian  Mcdiccd  Journal,  for  August,  1871,  by  Mr.  Mac- 
Gillivray,  surgeon  to  the  Bendigo  Hospital,  to  whom  I  am 
indebted   for   photographs    of  the  patient  (fig.   109).     The 

Fig.  109. 


patient,  a  woman  aged  twenty-nine,  seemed  to  have  suffered 
from  the  affection  in  both  jaws  at  or  soon  after  birth.  At 
the  age  of  ten  portions  of  the  gum  were  cut  away,  and 
several  teeth  extracted,  and  she  had  herself  in  later  life  cut 
off  portions  of  the  projecting  gum  with  a  razor.  All  these 
operations  gave  rise  to  severe  haemorrhage.  The  enormous 
growth  shown  in  the  drawing  seemed  to  have  originated 
mainly  from  the  palatal  portion  of  the  gums,  the  labial 
surface  being  comparatively  sound.  Mr.  MacGillivray 
removed  the  hypertrophied  gums  and  alveoli  with  perfect 
success. 

In  December,  1878,  I  brought  before   the   Odontological 


230  DISEASES   OF   THE   GUMS. 

Society  of  Great  Britain  two  cases  of  hypertrophy  of  tlie 
gums  which  I  had  treated  successfully  by  operation,  one  in 
a  child,  and  the  other  in  an  adult. 

The  first  case  was  that  of  Amy  B.,  ast.  four  years  and  a  half, 
who  was  admitted  into  University  College  Hospital,  May  6, 
1878.  She  is  one  of  five  children  ;  the  other  four  are 
healthy.  Two  years  ago  the  swelling  of  tlie  gums  began  by 
the  side  of  the  temporary  molars,  which  were  just  coming 
through,  and  from  them  the  swelling  has  spread  right  round 
the  jaw.  At  this  time  she  had  fits  about  once  a  week  ;  the 
fits  have  continued  up  to  the  present  time,  but  with  longer 
intervals.     They  appear  to  be  epileptic. 

The  patient  is  a  very  tractable  child  ;  her  general  health 
appears  to  be  good.  The  gums  are  enormously  hypertro- 
phied,  the  teeth  being  entirely  covered,  with  the  exception 
of  the  tips  of  the  crowns,  which  appear  depressed  in  the 
gums.  The  lower  gums  are  shown  in  fig,  110,  and  the  upper 
in  fig.  Ill,  taken  from  casts.      The  preparation  is  in  Univer- 

FiG.  110.  Fig.  111. 


sity  College  Museum  (1010  A).  Tlie  hypertrophy  of  the 
gums  is  so  great  that  the  cheeks  are  bulged  out  on  each  side, 
and  the  cavity  of  the  mouth  is  almost  filled  with  them. 
The  teeth  are  irregular  and  slightly  carious.  The  child  is 
always  biting  and  putting  cold  things  in  her  mouth.  She  can 
bite  nothing  hard,  and  has  been  fed  entirely  on  liquid  or 
pulpy  food.     Her  breath  is  very  offensive. 

Cn  May  9,  under  chloroform,  I  removed  tlie  hyper- 
trophied  gums  and  the  alveolar  margin  of  the  lower  jaw  in 
two  pieces.  On  one  side  the  first  permanent  molar  came 
away ;  on  the  other  side  it  was  left,  not  being  quite  erupted. 


HYPERTROPHY   OF   GUMS.  231 

Hiiemorrhagej  which  was  free,  was  stopped  with  the  actual 
cautery. 

On  May  23,  under  chloroform,  1  detached  the  hyper- 
trophied  gums  and  alveolar  border  of  the  upper  jaw  in  one 
semi-circular  piece.     Eoots  of  the  permanent  teeth  left. 

On  June  3  the  patient  was  discharged  well. 

A  microscopic  examination  by  Mr.  Charles  Tomes,  showed 
that  the  structure  of  the  growth  closely  resembled  that  of 
the  small  polypi  which  are  sometimes  found  occupying  the 
cavity  of  carious  teeth  :  it  was  a  true  hypertrophy  of  the 
gum,  and  chiefly  of  the  fibrous  portion.  It  sprang  from  the 
periosteum  round  the  neck  of  the  teeth,  just  within  the 
margin  of  the  alveoli.  From  this  point  a  dense  stroma  of 
interlacing  fibres,  covered  by  a  thin  mucous  and  epithelial 
layer,  grew  np  round  the  toothy  the  growths  from  opposite 
sides  meeting  over  it  and  coalescing,  so  as  almost  to  cover  it. 
The  attachment  within  the  socket  was  important,  for  this 
explained  how  it  was  that  a  successful  result  could  not  be 
obtained  without  removing  part  of  the  alveolus.  Unless  this 
was  done,  the  base  of  the  growth  was  left  behind,  and  recur- 
rence soon  took  place. 

The  second  patient,  Mr.  L.,  ^et  twenty-six,  came  under  my 
care  in  June,  1877,  with  hypertrophy  of  the  gum  and  alveoli 

Fig.  112. 


of  the  right  side  of  the  lower  jaw,  extending  from  the  right 
wisdom-tooth  to  the  left  canine.  The  affection  had  been 
noticed  from  early  childhood,  and  gave  no  pain.  The  condi- 
tion of  the  ofum  is  seen  in  fig.  112. 


232  DISEASES    OF    THE    GXTMS. 

On  June  19,  the  patient  being  under  chloroform,  I 
removed  the  affected  alveolus  with  Liston's  powerful  cross- 
cutting  forceps.  The  widom-tooth  was  left,  but  the  othei- 
teeth  were  necessarily  sacrificed  up  to  the  left  canine.  The 
haemorrhage  was  free,  but  was  controlled  with  the  actual 
cautery  freely  applied,  and  the  patient  made  a  good  recovery 
in  a  fortnight.  Mr.  Ibbetson  subsequently  fitted  some 
artificial  teeth ;  the  patient  is  now  in  much  gi*eater  comfort 
than  before. 

The  growtli  is  fibrous  in  structure^  and  is  an  example 
of  pure  hypertrophy.  The  preparation  is  in  University 
College  Museum  (1010). 

In  conclusion,  I  would  say  that  nothing  less  than  com- 
plete removal  of  the  affected  alveolus  seems  to  offer  any 
hope  of  alleviating  these  cases.  Mr.  Erichsen  in  1867 
thoroughly  pared  off  the  exuberant  growth  of  the  girl 
Ellen  S.,  but  in  1872  there  was  complete  reproduction  of 
the  disease.  In  the  child  operated  upon  by  me,  the  condition 
of  the  gums  was  such  as  mechanically  to  interfere  with 
taking  food,  so  that  there  was  no  hesitation  in  sacrificing 
the  temporary  teeth ;  and  it  may  be  hoped  that  many  of 
the  permanent  teeth  escaped  injury,  and  may  be  erupted 
in  due  course. 

Hypertrophy  of  the  gums  from  the  irritation  of  badly 
fitting  artificial  teeth  is  occasionally  met  with  in  elderly 
patients,  and  in  one  case,  a  lady  whom  I  saw  in  consulta- 
tion with  Mr.  Richardson,  and  in  whom  the  disease  had 
existed  for  ten  years,  I  found  it  necessary  to  remove  with 
Paquelin's  thermo-cautery  a  considerable  amount  of  tissue, 
before  it  became  possible  to  have  fresh  artificial  teeth  fitted. 

FoIi/j))'s  of  the  gum.  is  the  name  given  to  a  simple  hyper- 
trophy of  the  i^ortion  of  gum  between  two  teeth,  which  is 
ordinarily  dependent  upon  the  irritation  caused  by  those 
organs,  and  may  be  sessile  or  pedunculated.  It  is  often 
connected  witli  accumulations  of  tartar  around  the  necks 
of  the  teeth,  and  with  a  generally  unhealthy  condition  of 
the  mouth,  and  if  cut  away  with  scissors  and  freely 
cauterized  with   the  nitrate  of  silver,   or  better,  'Paquelin's 


VASCULAR    GROWTHS    OF   THE    GUMS.  233 

thermo-cautery,  does  not  recur.  In  one  case  of  large  polypus 
over  a  central  incisor  which  had  been  pivoted,  and  was 
doubtless  a  source  of  irritation,  I  thought  it  safer  to 
remove  a  small  piece  of  alveolus  with  the  bone-forceps 
after  extraction  of  the  tooth,  but  this  is  exceptional.  Mr. 
Salter  describes  a  condylomatous  form  of  disease  of  the 
gum  which  is  of  a  syphilitic  character. 

Vascular  cjrowths  are  occasionally  met  with  in  connection 
with  the  gum,  and  especially  in  the  region  of  the  incisor 
teeth.  These  bleed  freely  when  rubbed  with  the  tooth- 
brush, and  may,  if  neglected,  grow  to  some  size,  resembling  a 
nsevus  in  their  colour  and  appearance.  Stanley,  in  his  work 
"  On  Diseases  of  the  Bones,"  has  narrated  and  drawn  a  case 
in  which  there  was  a  vascular  growth  in  the  region  usually 
occupied  by  these  growths,  but  in  that  instance  the  tumour 
sprang  from  the  interior  of  the  jaw  and  necessitated  re- 
moval of  a  portion  of  it. 

Mr.  Tomes  has  successfully  treated  the  three  or  four 
examples  of  the  disease  he  has  met  witlij  by  the  frequent 
application  of  powdered  tannin.  Mr.  Salter  narrates  in  the 
"  System  of  Surgery,"  a  case  in  which  haemorrhage  arose  from 
a  growth  of  the  size  of  a  marble,  which  he  successfully  treated 
by  excision  and  the  application  of  the  actual  cautery,  after 
having  failed  to  effect  a  cure  with  the  ligature.  I  have  also 
met  with  an  example  of  pedunculated  tumour  of  the  gum  in 
a  woman  aged  twenty-five ;  it  bled  when  touched,  and  the 
pedicle  apparently  passed  through  the  alveolus.  I  removed  it 
in  June,  1869,  by  tearing  tlirough  the  pedicle  with  the  finger 
nail,  and  applied  the  actual  cautery  to  the  spot  from  which 
it  grew,  which  bled  freely.  I  have  twice  met  with  a  very 
vascular  and  hypertrophied  condition  of  the  gums  in  patients 
the  subjects  of  "  port-wine  stain"  of  the  face.  In  a  young 
married  woman  of  twenty- four,  the  gums  of  both  jaws  on 
one  side  were  affected,  and  became  more  developed  and 
vascular  during  each  jjregnancy,  so  that  she  lost  a  good  deal 
of  blood.  I  twice  removed  the  growth,  arresting  the 
haemorrhage,  which  was  not  severe,  with  the  actual  cautery. 
In  the   other  case,  of  a  young  lady  of  seventeen,  the  lip 


234 


DISEASES   OF   THE   GUMS. 


and  upper  gum  were  affected,  and  I  was  able  to  bring  about 
a  cure  by  drilling  with  a  sliarp-pointed  cautery. 

Papilloma  of  the  Gum. — ]\Ir.  Salter  has,  in  the  Guys 
Hospital  Reports  (1866),  called  attention  to  a  rare  form  of 
disease  in  connection  with  the  jaws,  which  appears  to  consist 
essentially  in  a  hypertrophy  of  the  papillfe  of  the  mucous 
membrane.  The  disease  was  first  noticed  by  Sir  William 
Fergusson,  in  the  lower  jaw  of  an  old  man  of  eighty,  and 
*' looked  like  vegetable  matter,  or  greatly  elongated  papilla," 
as  described  in  some  clinical  observations  on  the  case  by  that 
surgeon  in  the  Lancet,  September  6,  1862.  It  was  removed 
by  Sir  William  Fergusson,  and  is  described  by  Mr.  Salter  as 
"  a  curious  white  mass,  consisting  of  coarse  detached  fibres, 
pointed  and  free  at  one  extremity,  and  attached  at  the  other ; 
in  fact  it  was  a  mass  of  papillse,  many  of  them  nearly  an  inch 
long, and  similar  in  shape  to  the  'filiform'  papilkeof  the  tongue; 
their  surface  was  shreddy  and  broken  ;  among  these  elongated 
processes  were  a  few  rounded  eminences  like  'fungiform' 
papillfe,  and  these  had  a  smooth  unbroken  surface."  The 
accompanying  drawing  (fig.  113)  for  which,  as  well  as  for 

Fig.  113. 


those  that  follow,  I  am  indebted  to  Mr.  Salter,  represents  a 
portion  of  the  tumour  of  the  natural  size.  Microscopically 
the  mass  consisted  almost  entirely  of  epithelium. 

Mr.  Salter  met  with  a  second  case  in  the  practice  of  Mr. 
Cock,  at  Guy's  Hospital.  It  consisted  in  a  growth  of  the 
size  of  a  split  chestnut  attached  to  the  hard  palate  of  the 
right  side,  and  extended  from  the  edge  to  near  the  median 
line,  as  seen  in  lig.  \\\  and  had  been  growing  about  eight 
months.  Mr.  Cock  extirpated  the  growth,  which  consisted 
of   a  hard   mass   of   fibrous   tissue,  surmounted    by  papilhe, 


EPULIS. 


235 


mainly  composed  of  dense  coherent  epithelium;  and  met 
with  considerable  difficulty  in  arresting  the  free  haemorrhage 
which  ensued.     Fig.  115  represents  a  section  of  the  growth 


Fig.  114. 


of  the  natural  size.     The  growth  recurred  after  some  time, 
and  took  a  malignant  form,  which  proved  fatal. 

Fig.  115. 


Eimlis, — The   growths   connected    more   or    less   closely 
with  the    gums  vary  somewhat  in  their    nature,   but    are 

Fig.  116. 


conveniently  classed  together  under  the  term   epulis.     The 
ordinary  form  of   the   disease   is  a  firm  fibrous  tumour,  of 


236  EPULIS. 

slow  gi'owtli,  ill  which,  in  many  instances,  some  fibro- 
plastic cells  are  intermingled.  Hence  modern  patholo- 
gists regard  epnlides  as  examples  of  ossifying  sarcomata 
(Cornil  and  Ranvier).  The  accompanying  drawing  (fig.  116), 
for  which  I  am  indebted  to  Mr.  Jonathan  Hutchinson,  gives  a 
good  idea  of  the  naked-eye  appearance  presented  by  a  section 
of  an  epulis  of  large  size.  This  form  of  the  disease  is 
closely  connected  with  the  fibrous  gum,  and  also  with  the 
periosteum  of  the  alveolus,  and  very  generally  small  spicula 
of  bone  are  prolonged  into  it  from  the  maxilla ;  the  mucous 
membrane  of  the  gum  is  stretched  over  the  growth.  Occa- 
sionally a  development  of  true  bone  takes  place  in  distant 
parts  of  the  growth,  as  in  the  specimen  drawn  above ;  so 
also  in  a  large  epulis  which  I  removed  from  the  upper  jaw 
of  a  young  woman,  and  which  accompanied  this  essay 
(College  of  Surgeons'  Museum,  2191),  a  nodule  of  bone  of 
considerable  size  is  developed  near  the  surface  of  the  growth 
and  quite  unconnected  witli  the  alveolus.  Mr.  Ca3sar 
Hawkins  mentions  (Medical  Gazette,  1846)  a  similar  occur- 
rence in  a  case  where  the  epulis  was  pedunculated. 

The  myeloid,  or  softer  and  more  vascular  form  of  epulis,  is 
composed  of  a  small  quantity  of  fibrous  tissue,  holding  in  its 
meshes  the  true  polynucleated  myeloid  cells,  or  "  myelo- 
plaxies."     The  drawing  from  which  fig.  117  was  taken  (also 

Fin.  117. 


given  me  by  Mr.  Hutchinson),  showed  the  vascular  appearance 
of  such  a  tumour  on  section,  the  one  in  question  having  formed 
a  large  overhanging  mass  upon  the  lower  jaw,  which  was 
excised  by  Mr.  Curling  in  1864. 

In  fig.  118  is  seen  a  section  of  a  well  marked  myeloid  epulis, 
removed  by  Mr.  Wilkes,  of  Salisbury  (College  of  Surgeons' 


MYELOID    EPULIS.  237 

Museum,  2192).  The  tumour  consists  of  a  semi-globular 
tirm  elastic  mass  attached  by  its  base  to  the  luargin  of  the 
alveolus,  from  within  which  it  springs.  Its  surface  is  smooth 
and  uniform,  and  of  a  dark  grey  colour,  mottled  with  purplish 

Fig.  118. 


spots.  On  section  it  can  be  traced  into  the  bone,  the  cut 
surface  being  for  the  most  part  of  a  greyish  yellow,  with 
patches  of  pink  and  purple.  The  microscopical  examination 
shows  interspersed  among  the  fine  fibrous  tissue  some  large 
irregular  disc-like  cells,  containing  numerous  bead-like  nuclei, 
and  the  growth  may  therefore  be  considered  similar  to  that 
described  by  Otto  Weber,  as  "  giant-celled  sarcoma." 

This  form  of  epulis  is  more  commonly  connected  with  the 
interior  of  the  alveolus  than  the  fibrous  variety ;  and  this 
fact  may  possibly  account  for  its  being  more  closely  allied 
to  the  endosteal  than  the  periosteal  structures.  In  fact, 
many  of  the  so-called  myeloid  epulides  are  really  only  out- 
growths from  myeloid  tumours  of  the  interior  of  the  jaw,  and 
hence  their  great  tendency  to  recur  if  insufficiently  removed. 
It  is  this  form  which,  wdien  irritated  and  ulcerated,  presents 
an  appearance  somewhat  resembling  malignant  disease.  Ir- 
regular nodules  of  bone  may  be  scattered  through  the  myeloid 
as  through  the  fibrous  variety,  and  the  occasional  occurrence  of 
a  cyst  in  connection  with  an  epulis  must  not  be  overlooked.  I 
have  recently  had  a  case  of  the  kind  under  my  care,  in  which 
the  presence  of  a  cyst  by  the  side  of  a  fibrous  epulis  gave  a 
formidable  appearance  to  a  simple  disease. 

A  form  of  epulis  possessing  some  of  the  characters  of 
epithelioma  is  occasionally  met  with.  A  specimen  which 
was  sent  to  me  in  a  perfectly  fresh  state  by  Mr.  Hutchinson, 
who  had  removed  it  from  the  lower  jaw  of  a  lady  aged  fifty- 


238  EPULIS. 

five,  where  it  had  been  growing  a  year,  was  examined  by 
the  late  Mr.  Bruce  with  the  following  report : — "  The  surface 
of  the  tumour  is  covered  with  healthy  mucous  membrane. 
The  interior  of  the  tumour  is  whiter,  firmer,  and  more  com- 
pact than  the  surface  ;  but  there  is  no  line  of  demarcation 
between  the  tumour  and  its  mucous  covering.  The  structure 
of  the  growth  is  distinctly  glandular,  very  much  resembling 
some  forms  of  compact  adenoid  tumour  of  the  breast.  At 
the  point  of  attachment  of  the  tumour  to  the  parts  beneath, 
a  remarkable  transformation  of  the  glandular  into  the  epithe- 
liomatous  structure  is  seen.  In  one  part  of  the  section  may 
be  seen  the  cut  ends  of  gland  tubules,  whilst  in  their  im- 
mediate neighbourhood  are  most  distinct  nests  of  true  epithe- 
lioma, consisting  evidently  of  concentrically  arranged  cells 
compressed  from  the  centre  outwards."  ' 

Mr.  Eve  has  also  placed  in  tlie  Museum  of  the  College  of 
Surgeons  an  epulis  (2193  A)  which  microscopically  had  the 
character  of  an  epithelioma,  but  contained  no  "cell-nests." 

Epulis  appears  to  be  generally  connected  with  the  presence 
of  teeth,  and  in  some  cases  to  depend  upon  the  irritation 
caused  by  them ;  but  I  have  once  seen  a  small  fibrous  epulis 
in  a  newly-born  child.  The  simplest  form  is  often  found  grow- 
ing between  two  perfectly  sound  teeth,  which  become  widely 
separated,  as  seen  in  the  illustration  (fig.  119),  taken  from  a 

Fig.  119. 


patient  of  Dr.  Langston,  in  whom  I  was  obliged  to  sacrifice 
the  central  incisors  in  order  to  remove  the  growth ;  in  some 
instances  the  pedicle  attaching  the  growth  may  be  so  slender 
as  to  be  broken  by  the  tongue  of  the  patient  or  the  finger  of 
the  surgeon,  of  which  Sir  William  Fergusson  giveg  examples. 
The  teeth  may  be  unsound  and  broken,  and  in  these  cases 


STATISTICS    OF    EPULIS.  239 

Tcibular  Statement  of  Tiuenty-eight  Cases  of  Epulis. 


No, 

Sex 

Age 

j 
Duration. 

Position. 

Result. 

Remarks. 

1 

F. 

35 

Upper. 

Recovered. 

2 

M. 

39 

15  months. 

Recovered. 

3 

F. 

60 

7  months. 

Upper. 

Recovered. 

4 

F. 

50 

3  months. 

Upper. 

Died. 

Rigors  followed  the  opera- 
tion, and  death  from  py- 
aemia on  the  15th  day. 

5 

M. 

16 

3  years. 

Lower. 

Recovered. 

6 

F. 

60 

20  years. 

Upper. 

Recovered. 

Very  large  indeed.    It  had 
returned  after  removal  8 
years  before. 

7 

F. 

26 

9  months. 

Lower. 

Recovered, 

Large,  ragged,  andfungat- 
ing.    It  was  fibro-cartila- 
ginous. 

8 

M. 

36 

Upper. 

Recovered. 

It  vviis  thought  after  re- 
moval to  be  of  cancerous 
nature. 

9 

M. 

27 

7  years. 

Upper. 

Recovered. 

The  tumour  was  thought 
to  be  cancerous  after  re- 
moval. 

10 

F. 

28 

6  years. 

Lower. 

Recovered, 

The  tumour   consisted  of 
hardish  bone,  and  had  en- 
capsuled  completely  the 
stumps  of  two  teeth. 

11 

F. 

11 

Lower. 

Recovered. 

12 

F. 

36 

18  months. 

Lower. 

Recovered. 

Caused  by  a  decayed  tooth. 

13 

M. 

24 

Recovered. 

14 

F. 

30 

Upper. 

Recovered. 

15 

F. 

23 

14  months. 

Lower. 

Recovered. 

Two  bicuspid  teeth    were 
buried  in  it.     It  was  of 
myeloid  structure. 

16 

F. 

22 

2  years. 

Recovered. 

It  involved  two  teeth. 

17 

M. 

16 

1  year. 

Lower. 

Recovered. 

It  involved  the  last  bicus- 
pid and  first  molar. 

18 

F. 

31 

Lower. 

Recovered. 

The  tumour  was  soft  and 
fungoid. 

19 

F. 

30 

Lower. 

Recovered. 

20 

M. 

9 

Recovered. 

21 

F. 

22 

Lower. 

Recovered. 

22 

M. 

40 

Recovered. 

23 

M. 

40 

Recovered. 

It  was  ulcerated,  and  con- 
sidered to  be  malignant. 

24 

M. 

10 

Lower. 

Recovered. 

As  large  as  a  walnut. 

25 

M. 

61 

Upper. 

Recovered. 

26 

F. 

47 

5  months. 

Upper. 

Recovei-ed. 

27 

F. 

24 

Lower. 

Recovered. 

The   bleeding   which   fol- 
lowed required  the  actual 
cautery  for  its  arrest. 

28 

F. 

73 

Recovered. 

The  tumour  was  peduncu- 
lated, and  was  removed 
by  ligature. 

240  EPULIS. 

the  growth  often  completely  envelops  tlie  stumps  and  hides 
them  from  view,  or  in  the  progress  of  the  growth  a  fang  of 
a  tooth  may  be  pushed  forward,  and  be  eventually  found 
imbedded  in  its  centre,  as  narrated  by  Mr.  Tomes. 

The  accompanying  statistics  respecting  epulis  (p.  239), 
founded  upon  twenty-eight  cases  observed  in  the  London 
Hospitals,  are  taken  from  the  Medical  Times  and  Gazette, 
Sept.  3,  1859. 

"  Of  these  twenty-eight  cases  in  which  tumours  growing 
from  the  gum  were  of  the  character  usually  designated  as 
'  Epulis,'  we  may  make  the  following  summary  : — In  but 
one  instance  did  the  operation  cause  the  death  of  tlie  patient, 
whilst  in  all  the  others  the  parts  implicated  are  stated  to 
have  healed  soundly.  It  would  appear  that  the  female  sex 
is  mure  liable  to  this  disease  than  males,  in  the  proportion  of 
hve  to  three,  the  numbers  in  the  list  being  seventeen  females 
and  eleven  males.  This  may  perhaps  be  explained  by  reference 
to  the  fact,  that  stumps  of  decayed  teeth  are  by  far  the  most 
frequent  exciting  causes  of  these  growths.  Now,  women  are, 
for  several  reasons,  more  likely  to  retain  useless  stumps  of 
teeth  than  men.  They  are  far  more  patient  as  regards  severe, 
unavoidable  pain,  sucli  as  tliat  of  toothache,  and  at  the  same 
time  nmch  more  afraid  of  surgical  pain,  as  that  of  tooth  ex- 
traction ;  besides,  it  must  be  remembered,  that  the  conditions 
either  of  pregnancy  or  lactation  prevent  many  women  from 
having  their  decayed  teeth  taken  out  at  the  time  when  tliey 
ache. 

"  As  it  regards  age,  we  find  that  the  youngest  patient  was 
a  boy  of  9,  and  the  next  to  him  a  girl  of  11,  whilst  the 
oldest  was  a  woman  of  73,  and  the  next  to  her  another 
woman  of  60.  Five  were  under  the  age  of  20 ;  eight  between 
those  of  20  and  30 ;  seven  between  30  and  40 ;  three  be- 
tween 40  and  50  ;  two  between  50  and  GO  ;  and  three  above 
60.     The  average  age  of  tlie  wliole  number  is  33." 

The  two  jaws  appear  to  be  equally  liable  to  the  disease, 
but  its  position  and  extent  are  subject  to  great  variation.  In 
the  simplest  form  it  may  be  connected  with  only  the  outer 
plate  of  the  alveolus,  or  may  be  attached  at  a  slight  depth 


EPULIS.  241 

within  the  socket  of  a  tooth.  In  other  instances  it  is  at- 
tached solely  to  the  posterior  plate  of  the  alveolus,  and  pro- 
trudes the  teeth  or  appears  behind  them  ;  in  the  more  severe 
cases  of  myeloid  disease  it  involves  the  whole  thickness  of 
the  jaw,  and  either  envelops  or  carries  the  teeth  before  it. 
Of  this  a  case  of  Dr.  Fleming's  {Dublin  Quarterly  Journal, 
Feb.  1866),  gives  a  good  example  at  an  unusually  early  age, 
the  boy  being  between  five  and  six,  and  the  disease  occurring 
between  the  first  and  second  temporary  molar  teeth  of  the 
lower  jaw,  both  of  which  were  displaced  and  imbedded  in 
the  morbid  growth. 

When  the  tumour  attains  a  moderate  size,  if  it  be  on  the 
upper  surface  of  the  alveolus  it  is  apt  to  be  pressed  upon  by 
the  teeth  of  the  opposite  jaw,  and  this  not  only  gives  rise  to 
pain  and  inconvenience,  but  causes  also  indentations  and 
possibly  ulcerations  on  its  surface.  Fig.  120  is  reduced  from 
a  cast  of  the  upper  jaw  of  a  young  woman,  a  patient  of  Mr. 

Fig.  120. 


Warn,  of  the  Highgate  Road,  from  whom  I  removed  a  large 
epulis  containing  bone,  which  has  been  already  referred  to. 
The  patient  was  twenty-seven  years  of  age,  and  the  growth 
had  existed  two  years,  and  it  will  be  seen  that  the  surface  is 
grooved  and  indented  by  the  teeth  of  the  lower  jaw.  In  this 
case  the  fangs  of  the  first  and  second  molar  teeth  were  found 
in  the  alveolus  beneath  the  epulis. 

A  fibrous  epulis,  if  allowed  to  grow  to  a  large  size,  will 
produce  external  deformity  of  the  face,  and  although  attached 
to  the  upper  jaw  may  hang  down  so   as  to  simulate  disease 


242 


EPULIS. 


of  the  lower  jaw.  This  was  well  seen  in  a  woman,  aged 
twenty-seven,  who  had  an  epulis  of  the  upper  jaw  of  seven 
years'  growth,  which  hung  down  to  the  level  of  the  angle  of 
the  jaw,  and  who  was  under  the  care  of  Mr.  Erichsen,  by 
whom  the  tumour  was  removed  in  1861,  with  perfect  success. 
Perhaps  the  most  remarkable  case  of  epuloid  growth  on 
record,  however,  is  Mr.  Listen's  well-known  patient,  Mary 
Griffiths,  from  whom,  in  October,  1836,  he  removed  the 
growth  shown    in    the   accompanying    drawing   (fig.  121). 


Fig.  121. 


The  case  is  reported  at  length  in  the  Lancet  of  November  5, 
1836,  and  is  also  referred  to  in  Mr.  Listen's  "  Practical 
Surgery,"  from  which  botli  the  illustrations  are  taken. 
The  following  summary  of  it  is  from  a  note  to  Mr.  Listen's 
paper  on  Tumours  of  the  Jaw  in  the  Medico-Chirurgical 
Transactions,  vol.  xx. 

"  The  patient  had  laboured  under  the  disease  for  eight 
years,  and  had  been  subjected  to  a  partial  removal  of  the 
growtli  when  of  inconsiderable  size.      The  tumour  was  of  the 


MR.    LISTONS    CASE. 


243 


same  nature  as  those  of  the  third  and  fourth  cases  related 
in  the  paper  (i.e.,  fibroid),  as  regards  its  disposition,  form, 
and  intimate  structure.  It  differed  somewhat,  however,  in 
outward  appearance,  in  consequence  of  its  exposed  situation. 
Tlie  growth  sprang  originally  from  the  gums  and  sockets  of 
the  incisors  and  canine  tooth  of  the  left  side  ;  at  an  early 
period  it  protruded  from  the  mouth,  unconfined  and  uninflu- 
enced by  the  pressure  of  the  lips  or  cheek.  It  had  assumed 
a  most  formidable  size  and  appearance,  concealed  the  palate 
and  pharynx,  and  gave  rise  to  great  inconvenience  and  con- 
tinued suffering.  The  surface  had  been  broken  by  ulcera- 
tion, but  upon  a  close  inspection  of  the  projecting  part  and 
of  that  covered  by  the  cheek,  it  was  found  to  possess  a  firm 
consistence,  and  to  present  the  same  peculiar  botryoidal 
arrangement  of  its  parts  as  the  others  of  a  simple  and 
benign  nature.     The  operation  proved  perfectly  successful." 

Fig.  122. 


Fig.   122  shows  the  after-condition  of  the  patient,  the  scars 
in  the  upper  lip  being  the  result  of   the  previous  unsuc- 

n  2 


244  EPULIS. 

cessful  attempt  to  remove  tlie  disease.  The  preparation  is 
in  the  Museum  of  the  College  of  Surgeons  (2193). 

A  case,  very  similar  in  many  respects  to  the  preceding  one, 
was  successfully  operated  upon  in  1869  by  Professor  Kiuloch, 
of  Charleston.  The  patient  was  a  negress  aged  twenty-five, 
and  presented  much  the  appearance  shown  in  fig.  121,  the 
mouth  being  enormously  distended  by  a  protruding  growth, 
which  appeared  to  have  originated  in  the  alveolus,  but  to 
have  involved  the  superior  maxilla.  Dr.  Kinloch  removed 
the  mass,  which  weighed  nearly  two  pounds,  and  the 
patient  made  a  good  recovery. 

Treatment  of  Epulis. — No  treatment  less  radical  than 
removal  of  the  growtli  is  of  the  slightest  advantage.  In  the 
case  of  a  small  epulis  growing  betwee-n  or  close  to  the  in- 
cisor teeth,  after  removal  with  the  knife,  an  attempt  may  be 
made  to  check  the  reproduction  of  the  disease  by  the  appli- 
cation of  nitrate  of  silver,  or  a  fine  cautery,  but  usually  with- 
out success.  An  epulis  attached  to  the  outer  surface  of  the 
alveolus  only,  may  be  broken  away  with  the  nail,  and  the 
surface  be  thoroughly  cauterized,  but,  as  has  been  already 
said,  the  growth  is  connected  with  the  periosteum,  and  will 
often  be  rejaroduced  from  it.  It  is  essential  then  to  remove 
the  periosteum,  and  this  may  be  done  with  a  chisel  or  gouge, 
by  which  a  small  scale  of  the  alveolus  with  its  covering  can 
be  cut  away.  Tliose  who  object  to  such  a  proceeding  may 
produce  the  same  result  by  the  application  of  such  a  powerful 
caustic — either  potassa  fusa,  nitric  acid,  or  the  hot  iron — as 
shall  destroy  the  surface  of  the  bone  and  cause  its  exfoliation, 
l)ut  wit] I  some  tediousness  and  inconvenience  to  the  patient. 
In  cases  of  large  fibrous  epulis,  a  tooth  must  be  extracted  on 
each  side,  and  the  wliole  thickness  of  the  alveolus  cut  away 
with  bone  forceps,  of  whicli  Listen's  cross-cutting  forceps, 
shown  in  figs.  123  and  124,  are  very  serviceable  ;  the  straight 
ones  for  tlie  incisor,  and  the  angular  for  the  molar  region. 
The  same  radical  treatment  will  be  advisable  when  the 
disease  springs  from  tlie  posterior  plate,  and  in  all  these  cases 
I  make  an  invariable  practice  of  applying  the  actual  cautery 
to  the  surface  of  bone  exposed  by  the  operation,  which  has 


TREATMENT    OF   EPULIS.  245 

the  advantage  of  stopping  haemorrhage,  and  of  causing  the 
exfoliation  of  any  diseased  portions  of  bone  which  may- 
have  been  left.  In  all  operations  of  the  kind,  any  roots  of 
decayed  teeth  which  may  be  discovered  at  the  time  of  the 
operation  should  be  extracted  with  the  forceps  or  elevator, 
and  the  surface  of  the  bone  rendered  as  smooth  as  may  be. 

Fig.  123.  Fig.  124. 


When  the  epulis  is  connected  with  the  lining  membrane  of 
the  socket  of  a  tooth,  and  dips  down  into  the  interior  of  the 
jaw,  it  is  probably  myeloid,  and  no  superficial  operation  can 
efiect  a  cure,  since  it  is  in  this  class  of  cases  that  repeated 
reproductions  are  met  with.  The  neighbouring  teeth,  although 
sound,  must  generally  be  sacrificed,  and  the  alveolus  be 
thoroughly  cleared  out  with  the  gouge,  so  that  nothing  but 
the  shell  ol  compact  bone  is  left.  The  hemorrhage  is  usually 
free,  and  is  best  controlled  by  stuffing  the  cavity  with  lint. 
In  1875  I  saw  a  young  gentleman,  aged  nineteen,  with  Mr. 
Braine,  in  whose  lower  jaw  there  was  a  small  myeloid  growth, 
which  I  freely  removed.  Eecurrence  took  place,  however, 
and  I  operated  a  second  time,  clearing  out  the  alveolus  very 
thoroughly,  but  fortunately  being  able  to  preserve  the  teeth, 
and  the  patient  is  now  quite  well,  eight  years  afterwards. 

"When  the  epulis  is  very  extensive,  it  may  be  conveniently 
removed  with  the  alveolus  to  which  it  is  attached,  by  making 


246 


EPULIS. 


a  vertical  incision  with  a  small  saw  at  each  extremity  of  the 
disease,  and  then  connecting  the  cuts  by  a  horizontal  one 
with  cross-cutting  bone  forceps.  Under  no  circumstances, 
except  when  the  growth  is  of  a  malignant  character,  can 
it  be  necessary,  I  believe,  to  cut  through  the  whole  thickness 
of  the  lower  jaw,  since  it  has  been  shown  repeatedly  that 
common  epulis  never  involves  the  base  of  the  bone,  and  the 
contour  of  the  face  depends  so  much  upon  its  preservation, 
that  it  should  not  be  interfered  with. 

When  the  growth  is  of  large  size  and  situated  at  the  side 
of  the  mouth,  some  difiiculty  may  be  experienced  in  extir- 
pating it,  but  with  properly  made  angular  and  semicircular 
bone-forceps  .(tigs.  125  and  126)  this  may  generally  be  over- 


Fio.  125. 


Fig.  126. 


come,  it  may  be  necessary,  however,  to  incise  the  face, 
and  if  so,  the  suggestion  and  practice  of  Sir  William  Fer- 
gusson  ("  Lectures  on  Progress  of  Surgery,"  p.  239)  cannot 
be  too  strictly  followed — viz.,  to  restrict  the  incision  to  the 
middle  line  of  the  lip,  which  will  ordinarily  give  abundance 
of  room ;  or,  if  not,  to  carry  it  into  the  nostril  of  the  affected 
side,  by  the  stretching  of  which  so  much  additional  room 
will  be  gained  as  to  render  any  incision  at  the  angle  of  the 
mouth  perfectly  unnecessary.  When  tliis  limited  incision 
is  adhered  to,  the  scar  is   so   slight   as  to  be   imperceptible 


TREATMENT    OF    EPULIS.  247 

except  upon  the  closest  investigation.  In  instances  of  snch 
enormous  growths  as  in  the  case  of  Mary  Anne  Griffiths, 
more  extensive  incisions,  resembling  those  for  excision  of 
the  jaw,  would  be  required  ;  but  such  cases  are  now-a- 
days  few  and  far  between.  Mr.  Listen  considered  it  neces- 
sary to  remove  the  left  and  a  portion  of  the  right  maxilla, 
but  subsequent  examination  showed  that  these  bones,  though 
overlain  by  the  disease,  were  not  implicated  in  it  except  at 
their  alveolar  borders. 


248 


CHAPTER  XVI. 

TUMOUKS     OF     THE     PALATE. 

Tiwiours  of  the  Hard  Palate  are  for  the  most  part  closely 
allied  to  epulis,  and  may  therefore  be  conveniently  consi- 
dered here.  A  case  of  papilloma  of  the  hard  palate  has 
been  already  described  under  the  section  of  Papilloma 
of  the  Glim.  In  the  Museum  of  St.  Bartholomew's  Hospital 
is  a  preparation  (XII.  1800),  to  which  the  following  descrip- 
tion is  appended — "  An  elongated  oval  tumour  removed 
from  the  palate,  to  which  it  appears  to  have  been  attached 
by  a  broad  base.  It  is  composed  of  a  firm,  very  closely- 
textured,  obscurely-fibrous  substance,  with  interspersed  specks 
of  bone,  like  the  epulis  which  more  commonly  grows  from 
the  gums." 

Of  this  same  character  was  a  tumour  of  the  hard  palate 
removed  by  Mr.  Keate,  which  Mr.  Caesar  Hawkins  speaks 
of  as  essentially  the  same  as  epulis.  Mr.  Syme  also  narrates 
a  case  {British  Medical  Journal,  April  19,  1862)  occurring 
in  a  woman  aged  forty-six,  which  had  been  growing  two 
years,  was  of  a  circular  form,  and  "  presented  a  convex  sur- 
face extending  from  side  to  side  and  stretching  from  the 
anterior  third  of  the  palate  to  the  posterior  edge  of  its  hard 
portion."  The  growth  was  soft  at  its  centre,  but  hard  at 
the  base  and  evidently  connected  with  the  bone.  Unfor- 
tunately no  more  detailed  account  of  the  structure  of  the 
growth  is  given  in  the  lecture  in  question. 

Tumours  of  the  palate  of  a  softer  consistence  have  been 
met  with,  however;  thus  i\\  St.  Bartholomew's  Museum 
(XII.  1799)  are  sections  of  a  tumour  removed  from  the 
palate,  to  which  it  was  attached    by  a  base  of  much    less 


TUMOURS  OF  THE  PALATE.  249 

extent  thau  its  circumference.  Its  surface  is  covered  by 
thick,  but  apparently  healthy,  mucous  membrane,  and  its 
interior  is  lobulated. 

Encysted  tumours  of  the  palate  have  also  occurred ;  thus 
Dr.  Cabot  showed  to  the  Boston  Society  for  Medical  Im- 
provement a  small  round  tumour,  which  he  had  removed 
from  the  roof  of  the  mouth  of  a  soldier.  It  had  existed  for 
eighteen  months,  and  was  situated  on  the  posterior  and  left 
part  of  the  hard  palate,  extending  as  far  as,  but  not  in- 
volving, the  gum.  Although  the  patient  had  suffered  severe 
pain  in  the  left  side  of  the  face  and  temple  of  a  neuralgic 
character,  yet  he  was  not  sure  that  it  had  its  origin  in  the 
tumour.  It  was  somewhat  tender  on  pressure,  but  not  pain- 
ful. Tlie  capsule  which  contained  it  being  incised,  it  was 
easily  shelled  out.  It  was  two-thirds  of  an  inch  in  diameter, 
of  a  yellowish-white  colour,  and  mostly  smooth ;  but  in  one 
part  it  had  a  warty  appearance. 

A  very  similar  case  was  under  my  care  in  1876,  of  which 
the  following  are  the  details  : — S.  E — ,  aged  forty-eight,  was 
admitted  on  August  29,  1876.  She  stated  that  she  had 
noticed  a  small  lump  on  the  hard  palate  since  childhood,  but 
it  gave  her  no  inconvenience  until  about  two  years  ago,  when 
it  began  to  enlarge,  and  from  this  time  it  steadily  grew,  and 
soon  began  to  interfere  with  her  articulation.  Her  health 
had,  however,  always  been  good.  There  was  no  history  of 
tumour  in  the  family.  The  tumour  filled  up  the  hollow  in 
the  hard  palate,  being  more  attached  to  the  left  side,  where 
the  mucous  membrane  was  continued  directly  over  it,  than 
on  the  right,  where  a  probe  could  be  passed  between  the 
tumour  and  the  palate.  It  was  about  the  size  of  a  horse- 
chestnut,  slightly  lobed  on  the  surface,  elastic,  but  not  fluc- 
tuating ;  the  mucous  membrane  over  it  was  not  adherent  to 
it,  and  was  normal  in  appearance.  The  tumour  moved 
slightly  over  the  bone.  There  were  no  enlarged  lymphatic 
glands  in  the  neck.  The  accompanying  woodcut  (fig.  127) 
was  made  from  a  plaster  cast  taken  by  a  dentist. 

I  removed  the  tumour  by  making  an  incision  round  the 
left  side  of  the  growtli,  which  then  readily  shelled  out  from 


250 


TUMOURS    OF   THE    PALATE. 


a  distinct  capsule  ;  the  capsule  itself  was  afterwards  removed 
with  the  fingers.  Bleeding  was  stopped  by  the  actual 
cautery.  The  wound  granulated,  but  left  a  part  of  the  hard 
palate  bare.     A  small  portion  of  this  was  loose   when  the 


Fig.  127. 


patient  left  the  hospital,  and  she  stated  that  when  she  drank 
Ikiid  came  into  the  left  nostril. 

The  tumour  was  examined  microscopically,  and  found  to 
be  a  small  round-celled  sarcoma. 

A  very  similar  tumour,  removed  by  Sir  W.  Fergusson, 
is  preserved  in  the  Museum  of  the  College  of  Surgeons 
(2284),  being  a  round-celled  sarcoma,  half  an  inch  in 
diameter,  removed  from  a  woman  of  thirty-live,  in  whom  it 
had  been  growing  four  years. 

In  the  same  Museum  (2284  A)  is  a  carcinomatous  tumour, 
one  inch  in  diameter,  consisting  of  septa  bounding  alveoli, 
which  contain  collections  of  epithelial  cells,  removed  by  Mr. 
Bryant ;  and  in  the  Museum  of  King's  College  is  a  specimen 
of  the  kind,  in  wliich  the  greater  part  of  the  right  side  of  the 
hard  palate  is  involved  in  a  soft  tumour,  the  surface  of  which 
is  \evy   ii  regular  and  broken  d(nvn,   vvliilst   the   soft   palate 


TUMOURS    OF  THE   PALATE.  251 

appears  to  be  free  from  disease.  This  was  removed  from 
the  body  after  death,  and  no  history  is  appended  to  it. 

A  case  of  epithelial  tumour  of  the  palate  in  a  young 
woman,  aged  sixteen,  occurred  in  the  London  Hospital  in 
1856,  under  the  care  of  Mr.  Curling,  who  successfully  re- 
moved the  growth  with  a  large  portion  of  the  jaw  ;  the  case 
will  be  found  in  the  Lancet,  July  26,  1856. 

Sir  Andrew  Clark's  report  of  the  tumour  is  as  follows  : — 
"  The  tumour  is  about  the  size  and  of  the  shape  of  a  hen's 
egg.  It  is  invested  by  a  condensed  layer  of  areolar  tissue, 
and  loosely  connected  with  the  periosteum  of  the  adjacent 
bones.  At  one  point — the  posterior  and  inferior  edge  of 
the  zygomatic  surface  of  the  superior  maxillary  bone — it 
had  a  limited  but  distinct  osseous  attachment.  The  tumour 
therefore  might  have  been  shelled  out  at  all  points  but  this. 
The  tumour  lies  between  the  naso-palatine  portion  of  the 
right  maxilla  and  the  mucous  membrane.  The  mucous 
membrane  over  the  tumour  is  hypertrophied,  and  exhibits 
an  oval  ulcer  with  thick,  rounded,  white  margins,  and  a  red- 
dish, smooth  base.  The  naso-palatine  part  of  the  superior 
maxilla  is  elevated  and  thinned ;  the  periosteum  is  loosely 
attached  to  it,  and  at  one  point  the  bone  is  a  little  '  opened 
up'  in  texture.  The  tumour  is  soft,  slightly  elastic,  and 
vascular.  The  cut  surface  is  of  a  dead-white  colour,  dis- 
tinctly granular,  like  rough  honey,  crumbly-looking,  and 
studded  with  red  or  pink  blotched  parts  sunk  below  the 
general  level.  On  further  examination  it  appears  to  be 
permeated  by  a  kind  of  glairy  substance  (colloid  matter), 
which  helps  seemingly  to  give  coherence  to  the  tumour.  To 
the  naked  eye  the  tumour  resembles,  in  some  respects,  a 
cephaloid  or  myeloid  mass.  To  the  latter  it  bears  the 
greatest  resemblance  in  general  character,  seat,  and  struc- 
ture. The  microscopic  characters  are  those  of  epithelial 
cancer  J  epithelial  cells  in  all  stages  of  development  and  of 
the  most  various  forms,  together  with  a  few  nest-cells  and 
fat.  The  mucous  membrane  over  the  tumour,  though  not 
continuous  with  it,  presents  the  same  structural  characters. 
This  decides  the  doubt  between  epithelioma  and  myeloma. 


252  TUMOURS    OF   THE   PALATE. 

The  tumour  has  been  wholly  removed."  {Lancet,  July  26, 
1856.) 

But  epitheliomatous  ulceration  of  the  hard  palate  is  very 
often  the  result  of  extensive  epithelioma  of  the  antrum,  the 
floor  of  which  has  become  perforated,  this  being  in  some 
cases  the  first  evidence  of  the  disease.  The  consideration 
of  these  cases  will  be  found  in  a  subsequent  chapter. 

Treatment. — When  the  disease  is  of  the  epuloid  character 
the  treatment  should  be  the  same  as  for  that  disease — viz., 
complete  removal  and  destruction  of  the  periosteum,  from 
which  the  growth  springs.  When  the  bone  is  implicated 
too  deeply  for  the  disease  to  be  effectually  removed  with  the 
gouge,  the  plan  adopted  by  Mr.  Syme  in  the  case  already 
referred  to  may  be  adopted.  He  removed  the  growth  and 
the  subjacent  bone  with  a  trephine  large  enough  to  embrace 
the  whole  tumour,  leaving  an  aperture  with  healthy  edges, 
which  granulated  and  was  much  contracted  when  the  patient 
was  dismissed.  When  the  disease  is  too  extensive  to  be 
dealt  with  in  this  way,  it  will  be  necessary  to  remove  a 
portion  of  the  jaw,  as  in  Mr.  Curling's  case.  Under  these 
circumstances  the  limited  incision  already  insisted  upon  for 
cases  of  epulis  should  be  had  recourse  to,  and  the  jaw  should 
be  divided  horizontally  immediately  above  the  palatine  plate, 
so  as  to  do  as  little  damage  as  possible  to  the  appearance  of 
the  face. 

Tumours  of  the  Soft  Palate  may  be  dermoid  and  congenital, 
as  in  a  case  shown  at  the  Pathological  Society  in  April, 
1881,  by  Dr.  Hale  Wliite,  in  which  Mr.  Morrant  Baker 
removed  the  growth  with  a  ligature  ;  or  may  be  papilloma- 
tous, as  in  the  case  of  a  healthy  girl,  aged  eighteen,  who 
came  to  the  Dental  Hospital,  Leicester  Square,  to  have  some 
teeth  stopped  ;  on  examining  her  mouth.  Dr.  Ai-kovy  noticed 
a  growtli  attached  to  the  soft  palate.  It  was  pedunculated, 
hanging  down  beyond  the  margin  of  the  left  velum,  and  had 
a  warty  appearance ;  he  snipped  it  off  with  scissors  and 
rather  free  haemorrhage  followed. 

The  growth  was  about  half  an  inch  long  by  one-sixth 
of  an  inch  broad,  the  pedicle  being  about  one-eighth  of  an  inch 


TUMOURS    OF   THE    PAL.VTE.  253 

thick ;  it  was  of  the  same  colour  as  the  surrounding  mucous 
membrane,  and  the  surface  was  composed  of  enlarged 
fungiform  and  filiform  papillas.  On  a  longitudinal  section 
it  was  seen  to  be  composed  of  compound  papillae  branching 
off  from  a  common  root  or  base,  each  offshoot  being  com- 
posed of  dilated  blood-vessels,  surrounded  by  a  very  small 
amount  of  connective  tissue,  and  enclosed  by  a  thin  layer  of 
mucous  membrane,  on  which  were  several  layers  of  epithelium 
cells  of  the  pavement  variety. 

In  1879,  I  had  under  my  care  a  lady  with  a  very 
suspicious  tumour  of  the  soft  palate,  which  I  feared  would 
prove  to  be  sarcomatous.  On  incising  it,  however,  I  was 
able  to  enucleate  with  the  finger  what  proved  to  be  an 
adenoma  or  hypertrophy  of  the  glands  of  the  soft  palate, 
contained  in  a  distinct  cyst,  which  I  was  also  able  to  with- 
draw. The  patient  has  remained  in  perfect  health  to  the 
present  time. 

In  the  following  year  I  saw,  with  Sir  J.  Paget,  a  child 
aged  seven,  with  a  tumour  presenting  almost  precisely 
similar  appearances,  but  upon  cutting  into  the  growth  it 
proved  to  be  a  sarcoma  with  extensive  attachments  which 
did  not  admit  of  removal.  The  growth  steadily  increased 
and  destroyed  life  in  six  months. 

Looking  back  at  these  two  cases,  I  find  it  impossible  to 
give  any  symptom  by  which  they  might  have  been  distin- 
guished; but  the  duration  of  the  growth,  if  it  can  be  accurately 
ascertained,  would  doubtless  help  at  arriving  at  a  just 
conclusion. 

A  case  of  medullary  tumour  of  the  soft  palate  in  which 
the  tumour  was  excised  with  temporary  relief,  is  recorded  by 
Mr.  Langton  in  the  Clinical  Society's  Transactions,  vol.  iii. 


254 


CHAPTER  XVII. 

EPITHELIOMA    OF    THE    GUMS    AND    ANTRUM. 

Epithelioma  of  the  gums,  as  commonly  met  with,  cannot 
properly  be  included  among  the  epulides,  since  it  is  the 
exception  for  there  to  be  any  out-gTOwth  or  tumour  in  the 
early  stage  of  the  disease.  A  ragged  ulceration  of  the  gum, 
supposed  to  be  dependent  upon  some  tooth,  and  jDrobably 
the  du'ect  result  of  long-continued  irritation,  is  noticed,  but 
the  pain  is  not  marked  and  the  inconvenience  is  sliglit. 
Careful  observation  will  soon  detect  a  tendency  of  the 
ulceration  to  spread  both  towards  the  tongue  and  the  cheek, 
and  by  this  time,  probably,  induration  of  the  base  of  the 
ulcer  may  be  detected  where  it  touches  the  softer  tissues. 
The  importance  of  prompt  and  thorough  interference  cannot 
be  too  strongly  impressed  upon  members  of  the  dental 
profession,  by  whom  cases  of  epithelioma  are  most  generally 
seen  in  the  early  stage.  In  a  recent  case  of  ulceration  of 
the  gum,  simple  treatment  may  fairly  be  tried  for  a  week  or 
ten  days,  but  if  the  ulcer  still  remains  unhealed,  and  more 
particularly  if  it  is  increasing,  surgical  aid  should  at  once 
be  summoned.  The  frequent  application  of  the  solid  nitrate 
of  silver  to  an  ulcer  which  fails  to  heal  readily,  is  worse 
than  useless.  The  treatment  of  an  epitheliomatous  ulcer 
consists  in  thoroughly  destroying  it,  with  the  tissue  around 
for  some  distance.  In  slight  or  doubtful  cases  thorough 
application  of  the  strongest  nitric  acid,  the  acid  nitrate  of 
mercury,  or  better,  the  actual  cautery,  may  be  sufficient  to 
ensure  a  healthy  cicatrization ;  but  even  then  the  part  will 
require  careful  watching,  in  order  that  any  fresh  ^levelopment 
may  be  promptly  attacked.     Unfortunately  the  disease  has. 


EPITHELIOMA    OF   THE    GUMS.  255 

ill  the  majority  of  cases,  already  invaded  the  alveohis,  as  is 
shown  by  the  swelling  of  the  gum  and  the  loosening  of  the 
teeth,  and,  when  this  is  the  case,  free  removal  of  the  bone 
must  be  undertaken.  A  vertical  cut  with  a  narrow  saw 
being  made  through  the  whole  depth  of  the  alveolus  well 
beyond  the  disease,  the  cross-cutting  bone-forceps  may  be 
used,  or  the  saw  applied  horizontally  to  remove  the 
diseased  portion,  as  is  shown  in  fig.  128,  taken  from 
Fergusson.     The  danger  of  course  is  that  the  disease  may 


Fig.  128. 


have  penetrated  more  deeply  than  appears  into  the  bone,  so 
that  recurrence  is  apt  to  take  place  rapidly  from  the 
epitheliomatous  elements  left  behind.  Should  this  occur, 
there  must  be  no  hesitation  in  removing  the  whole  thickness 
of  the  bone,  and  in  the  incisor  region  the  resulting  incon- 
venience is  much  less  than  might  be  anticipated,  the 
muscles  attached  to  the  two  halves  of  the  jaw  forcing  them 
together,  so  that  tough  fibrous,  if  not  bony,  union  takes  place 
in  the  position  of  the  original  symphysis. 

Some  years  ago  a  man  was  sent  to  me  by  Mr.  Harding 
with  an  undoubtedly  epitheliomatous  growth  springing  from 
the  gum  in  the  incisor  region.  This  I  removed  by  sawing 
the  lower  jaw  horizontally  below  the  level  of  the  alveolus, 
but,  the  section  not  proving  quite  healthy  in  appearance,  I 
thought  it  advisable  to  take  away  the  whole  thickness  of 
the  jaw  in  this  region.  The  patient  made  a  good  recovery, 
with  firm  union  between  the  two  segments  of  the  jaw,  and 
I  have  not  heard  of  any  further  recurrence. 

An  equally  satisfactory  case  has  come  under  my  frequent 


256  EPITHELIOMA    OF   THE   GUMS. 

observation  during  the  last  three  years,  in  the  person  of  a  re- 
tired officer  of  the  army,  who  in  1879,  after  wearing  a  lower 
dental  plate  for  some  years,  developed  epithelioma  of  the  gums 
and  cheek.  Professor  Bowen  Partridge^  of  Calcutta,  removed 
the  left  half  of  the  body  of  the  jaw  in  December,  1879,  and 
recurrence  taking  place  at  the  chin.  Dr.  McLeod  removed  the 
right  half  in  March,  1880,  with  the  submaxillary  glands  of 
both  sides.  I  first  saw  this  gentleman  in  July,  1881,  when  the 
central  portion  of  the  jaw  was  of  course  gone,  and  there  was 
a  space  of  IJ  inches  between  the  halves  of  the  bone.  The 
tissues  around  were  contracted,  but  perfectly  healthy,  and 
his  only  complaint  was  a  sense  of  tightness  and  want  of 
saliva.  During  the  last  two  years  the  portions  of  jaw  have 
become  more  approximated,  and  the  growth  of  a  beard  hides 
the  want  of  chin;  and  as  nearly  four  years  have  now 
elapsed  since  the  operation,  the  cure  may,  I  presume,  be 
considered  permanent. 

In  the  Museum  of  the  College  of  Surgeons  are  two  speci- 
mens (2249  &  A)  of  epithelioma  of  the  alveolus  in  which  a 
less  satisfactory  result  followed.  The  patient  was  a  gentle- 
man, aged  fifty-four  when  he  was  sent  to  me  by  Mr.  Weiss, 
with  a  well-marked  epitheliomatous  condition  of  the  right 
lower  alveolus,  between  the  first  molar  and  the  canine  teeth, 
which  had  been  noticed  six  months.  In  addition,  a  well- 
marked  ichthyotic  condition  of  the  mucous  membrane  of  the 
floor  of  the  mouth  extended  along  the  inner  side  of  the  body 
of  the  jaw  and  beneath  the  tongue.  In  September,  1880,  I 
burnt  away  the  whole  of  the  aiiected  mucous  membrane  with 
Paquelin's  cautery,  and  having  deeply  notched  the  alveolus 
with  the  saw,  I  clipped  out  the  affected  portion  with  bone- 
forceps.  Two  months  later  the  disease  began  to  show  itself 
on  the  inner  side  of  the  jaw,  and  in  April,  1881,  I  removed 
the  part  affected  very  freely,  cutting  away  the  whole  thick- 
ness of  the  bone  from  the  second  molar  of  the  right  to 
the  second  incisor  of  the  left  side,  with  the  adjacent 
lymphatic  gland,  the  section  of  bone  being  apparently 
liealthy.  llecurrence  took  place,  however,  shortly,  and  in 
November  I  removed  a  further  portion  of  the  left  side  of  the 


EPITHELIOMA    OF   THE    ANTRUM.  257 

lower  jaw  up  to  the  first  molar  tooth  (College  of  Surgeons' 
Museum,  2249),  Notwithstanding  this  complete  removal  of 
the  disease,  it  returned  in  the  soft  parts  beneath  the  tongue, 
large  masses  protruded  into  the  mouth,  and  the  patient  sank 
in  November,  1882. 

Both  in  this  and  in  other  similar  cases  I  have  been  dis- 
appointed with  the  operation  of  removing  solely  the  alveolus,. 
and  am  inclined  to  adopt  more  radical  measures  at  first  in 
future,  being  encouraged  to  do  so  both  by  the  great  success 
of  the  officer's  case  already  mentioned,  and  by  a  case  occur- 
ring in  University  College  Hospital,  the  details  of  which 
will  be  found  in  the  Appendix  (Case  X.). 

Epithelioma  of  the  Antrum,  of  the  squamous  variety,  is  a 
very  insidious  disease,  which  gives  rise  to  the  formation  of 
no  tumour  of  the  face,  but  slowly  destroys  the  antrum  and 
spreads  thence  in  all  directions.  It  was  first  described,  from 
the  clinic  of  M.  Verneuil,  by  M.  Eeclas  ("  Progres  Medical," 
1876),  who  termed  it  very  aptly  Epithelioma  tiribrant  (bur- 
rowing or  boring  epithelioma),  and  attention  was  called  to 
it  by  Mr.  Butlin  in  1881.  I  had  at  the  time  two  cases  of 
the  kind  under  observation,  one  in  hospital,  which  was  at 
first  thought  to  be  epithelioma  of  the  palate,  but  in  which 
the  antrum  was  found  extensively  affected,  and  the  other  in 
private,  which  was  a  good  typical  example  of  the  disease. 
The  patient,  aged  sixty-six,  had  a  troublesome  and  loose 
upper  molar  tooth,  for  which  he  consulted  a  well-known 
dental  surgeon  in  the  West  of  England,  who  extracted  it,, 
bringing  away  a  soft  growth  attached  to  the  fangs.  The 
opening  was  found  to  communicate  with  the  antrum,  and 
shortly  a  fungus  growth  protruded,  and  there  was  a  good 
deal  of  discharge.  The  case  was  regarded  as  one  of  disease 
of  the  antrum,  which  was  well  syringed  out,  but  the  palate 
became  more  involved  and  the  cheek  somewhat  swollen. 
Wlien  I  saw  the  patient  in  September,  1881,  a  month  after 
the  extraction  of  the  tooth,  there  could  be  no  doubt  of  its 
serious  nature.  Under  chloroform  I  was  able  to  pass  my 
finger  through  the  fungus  completely  into  the  antrum,  which 
.was  widely  affected.     Turning  up  the  lip  without   incising 

S 


258  EPITHELIOMA    OF   THE   ANTRUM. 

it,  I  was  able  with  saw  and  bone-forceps  to  remove  the  floor 
of  the  antrum,  which  shows  very  well  the  disease  (College 
of  Surgeons'  Museum,  3247).  I  then  removed  the  back  of 
the  antrum^  but  the  orbital  plate  being  apparently  healthy, 
I  contented  myself  with  scraping  it  freely  and  applying  the 
chloride  of  zinc  paste,  the  age  of  the  patient  forbidding 
removal  of  the  whole  upper  jaw.  Eecurrence  took  place, 
and  I  again  scraped  away  the  growth  and  applied  the  zinc 
paste,  but  the  disease  again  made  progress,  and  the  patient 
died,  worn  out,  within  a  year  of  the  first  appearance  of  the 
disorder. 

Mr.  Butlin's  case  is  very  similar  {Patholofjical  Society's 
Transactions,  1881),  and  was  that  of  a  man  aged  sixty-two, 
who,  after  pain  in  the  jaw,  found  a  fistulous  opening  in  tlie 
palate,  from  which  a  foul  discharge  proceeded.  The  finger 
was  passed  easily  into  the  antrum,  and  the  cavity  was  cleared 
out,  and,  upon  recurrence  taking  place,  the  upper  jaw  was 
removed,  but  the  patient  sank  on  the  fifth  day.  Mr.  Butlin 
has  recorded  another  case  under  Mr.  M.  Baker  {Path.  Trans., 
1882),  in  a  woman  of  fifty-eight,  with  a  bulging  out  of  the 
right  cheek  and  an  opening  from  the  palate  into  the  antram. 
The  upper  jaw  was  removed,  but  the  disease  was  found  to 
have  already  spread  beyond  it,  and  the  patient  died  ex- 
hausted after  a  few  days. 

The  disease  appears  so  insidiously  and  spreads  so  rapidly 
to  the  deeper  parts  that  its  prompt  recognition  is  of  the 
greatest  importance,  and  it  may,  I  tliink,  be  held  that  the 
attachment  of  any  growth  to  the  fangs  of  extracted  teeth 
should  excite  suspicion  as  to  the  presence  of  serious  disease 
witliin  the  antrum.  M.  lieclus,  in  the  paper  referred  to, 
goes  so  far  as  to  suggest  that  the  disease  originates  in  one 
of  the  periosteal  cysts  of  the  fangs  of  the  teeth  already 
described,  but  it  seems  more  probable  that  it  starts  from  the 
socket  of  a  tooth,  and  derives  its  squamous  character  from 
the  palate. 

The  treatment  is  unsatisfactory,  because  the  age  of  tlie 
patient  forbids  extensive  operations,  such  as  wojild  be  neces- 
sary for  the  removal  of  the   upper  jaw.     In  my  own  cases, 


EPITHELIOMA    OF    THE    ANTRUM.  259 

in  which  I  was  content  to  operate  from  the  mouth,  the  patients 
survived  for  some  months,  whereas  in  the  two  cases  recorded 
by  Mr.  Butlin,  in  which  the  jaw  was  removed,  the  patients 
rapidly  sank. 

Mr.  G.  Lawson  has  recorded  {Clinical  Society's  Transac- 
tions, 1873)  a  case  of  this  disease,  in  which  he  adopted  a 
bolder,  and  apparently  more  successful  treatment — viz.,  to 
destroy  the  skin  over  the  growth  and  the  disease  itself  with 
the  actual  cautery,  and  then  to  apply  caustic  paste  freely  so 
as  to  obtain  large  sloughs.  The  patient  was  sixty-five,  and 
made  a  good,  and  it  is  believed,  permanent  recovery.  Of 
course  there  is  the  permanent  deformity  to  be  considered, 
but,  after  all,  this  is  a  slight  drawback  if  a  cure  can  be 
obtained,  and,  as  regards  immediate  danger  to  life,  Mr. 
Lawson  truly  remarks,  "  it  must  be  borne  in  mind  that 
patients  advanced  in  life  stand  cutting  operations  very  badly, 
whilst  they  will  bear,  with  but  little  shock,  the  destruction 
of  large  growths  by  escharotics." 


s  2 


260 


CHAPTER  XVIII. 

NON-xMALIGNANT    TUMOURS    OF    THE   UPPER    JAW. 

Fibroma,  UncJwndroma,  Osteoma. 

With  regard  to  the  statistics  of  tumours  of  the  upper  jaw, 
I  shall  content  myself  with  quoting  0.  Weher,  who  has 
collected  307  cases  from  the  following- sources  : — 183  cases 
tabulated  by  Heyfelder ;  36  recorded  by  Liicke  from  Lan- 
genbeck's  clinique  ;  17  reported  in  the  Medical  Times  and 
Gazette  (Sept.  3,  1859)  ;  and  71  cases  either  observed  by 
himself  in  Wutzer's  clinique,  or  occurring  in  his  own  prac- 
tice.     Of  the  above  cases  there  were : — 

Osseous  tumours 32 

Vascular  tumour 1 

Fibrous  tumours 17 

Sarcomatous  tumours 84 

Enchondromatous  tumours 8 

Cystic  tumours 20 

Mucous  polypi 7 

Carcinoma 133 

Malanosis 5 


307 


In  commenting  upon  this  table,  Weber  very  justly  re- 
marks that  doubtless  the  list  of  cancerous  cases  is  exag- 
gerated, and  suggests  that  a  fair  estimate  would  be  gained 
by  allotting  rather  more  than  a  third  of  the  whole  number 
to  sarcomatous  (simple)  tumours ;  less  than  one-third  to 
tlie  cancerous  ;  and  the  remainder  to  the  osseous  tumours,, 
cysts,  &c. 


FIBROMA    OF    THE    UPPER   JAW.  261 

It  must  be  borne  in  mind,  however,  tliat  modern  methods 
of  investigation  have  shown  that  the  old  classifications  are 
frequently  based  upon  erroneous  data,  so  that  a  re-arrange- 
ment of  tumours  of  the  jaws  has  become  necessary,  and  will 
Ijc  attempted  in  the  following  pages. 

Fibro7na. — This    closely  resembles   the    fibrous   tumom^s 
found  in  other  parts   of  the   body,   and  especially  in   con- 
nection with  the  uterus.     It  is  dense  in  structure  but  not 
unfrequently  lobulated,  and  on  section,  slender  bundles  of 
intersecting  fibres  may  occasionally  be  traced  in  them,  of 
which  there  are  good  examples  in  the  Museum  of  the  College 
of  Surgeons.     The  fibrous  tumour  usually  springs  from  one 
of    two   situations,    either    the  interior    of  the    antrum    or 
from  some  portion  of  the    alveolus.       In  both  cases  it  is 
intimately  connected   with  the  periosteum,  in   this   respect 
resembling    epulis.      Occasionally  the    growth    appears   to 
follow  some  slight  injury,  as  in  the  case  of  a  lady,  a  patient 
of  Dr:  Neale,  from  whom,  in  1870,  I  successfully  removed  a 
fibrous  tumour  occupying  the  interior  of  the  antrum,  which 
had  followed  a  blow  given  by  her  child,  and  which  may  have 
been  a  fibrous  odontoma  (p.  267).      The  fibrous  tumour  grows 
slowly  but  surely,  involving  in  its  progress  the  surrounding 
structures.     When  arising  in  the  antrum,  it  first  expands 
the  walls  of  that  cavity,  bulging  out  the  face  and  forming 
tumours  in  the  palate  and  floor  of  the  orbit,  and  subsequently 
produces  absorption  of  the  osseous  walls  and  spreads  un- 
checked in  all   directions.      The   following   description  of  a 
specimen  in    St.  George's   Hospital   Museum   gives  a  good 
idea  of   the  ravages  of   such  a   tumour  : — "  Fibrous  tumour 
growing    from   the    antrum,   and  making   its   w-ay  by   the 
absorption  of  the  walls  of  that  cavity  in  different  directions. 
It   projects   upwards  into  the    orbit,  destroying  the  floor  of 
that  cavity,  and  protruding  from  its  inner  margin  forwards 
on  to  the  cheek.      It  has  also  destroyed  the  anterior  wall  of 
the  antrum,  and  displaced  the  malar  bone  forward  and  out- 
ward ;  inwards  it  projects  into  the  nose  beneath  the  middle 
turbinated  bone,  and  downwards  it  makes  its  appearance  on 
tlie  under  surface  of  the  alveolar   process  in  the  form  of  a 


262      NON-MALIGNANT   TUMOURS   OF   UPPER   JAW. 

rounded  mass,  destroying  the  floor  of  the  antrum  in  the 
neighbourhood  of  the  front  molar  tooth.  Behind,  the 
tumour  appears  in  the  zygomatic  fossa  by  the  absorption  of 
the  outer  part  of  the  tuberosity  of  the  superior  maxillary 
bone.  The  tumour  is  composed  of  circular  nuclei  of  various 
sizes,  and  spindle-shaped  fibres.  The  patient  from  whom  the 
specimen  was  taken,  William  H.,  died  of  ararchnitis,  and 
softening  of  the  corresponding  part  of  the  brain." — Catalogue 
of  St.  Georges  Hospital  Museum  (II.  160). 

When  it  arises  from  the  alveolus,  a  fibrous  tumour  may 
encroach  on  both  tlie  facial  and  the  palatine  surfaces  of  the 
jaw,  crushing  in  the  antrum  although  not  involving  its  in- 
terior. Of  this  a  good  example  is  seen  in  a  preparation 
(2238)  in  the  College  of  Surgeons,  of  an  upper  jaw  removed 
by  Mr.  Liston.  Here  the  tumour  which  is  affixed  to  the 
alveolar  border,  near  the  molar  teeth,  extends  inwards  so  as 
to  cover  the  palatine  portion  of  the  jaw,  and  outwards  so 
as  to  conceal  all  the  bicuspid  and  molar  teeth,  with  the 
exception  of  the  last.  The  walls  of  the  antrum  are  pressed 
inwards,  but  its  interior  is  healtliy.  The  patient  was  a 
woman,  thirty  years  old,  and  the  tumour  was  observed  four 
years  before  its  removal,  which  was  successful.  On  the 
other  hand,  fibrous  tumours,  though  commencing  in  the 
alveolus,  may  secondarily  involve  the  antrum  when  they 
have  attained  considerable  size,  producing  complete  absorp- 

FiG.  129. 


tion  of  its  walls,  and  projecting  into  the    nose  and   through 
the  palate.     Of  this  a  preparation  in   the   College   of  Sur- 


FIBROMA    OF   THE    UPPER   JAW. 


263 


geons'  Museum  (2236),  of  an  upper  jaw,  also  removed  by 
Mr.  Liston,  affords  a  good  example.  Here  the  patient  was 
only  twenty-one,  and  the  growth  first  appeared  on  the 
outer  side  of  the  gum  of  the  left  upper  jaw  four  years  before 
the  operation.  It  was  cut  off  six  months  after  its  first 
appearance,  but  returned,  and  eighteen  months  after  was 
removed,  with  a  portion  of  the  alveolar  process,  but  reap- 
peared in  a  few  weeks.  Fig.  129,  from  Listen's  ''  Practical 
Surgery,"  shows  the  growth  after  its  removal,  and  figs.  130 
and  131  show  the  patient  before  and  after  the  operation. 
It  may  be  noticed  here,  as  in  the  case  of  a  large  epulis, 
that  disease  of  the  upper  jaw  often  closely  resembles,  exter- 
nally, a  tumour  of  the  inferior  maxilla. 


Fig.  130. 


Fig.  131. 


(ifeMk, 


r~~cr^ 


The  case  is  given  by  Mr.  Liston  in  his  paper  on  Tumours 
of  the  Jaw,  in  the  Medico-Chirurgical  Transactions,  vol.  xx. 

The  enormous  size  to  which  fibrous  tumours  of  the  upper 
jaw  may  grow  without  destroying  the  patient,  is  well  seen 
in  the  accompanying  drawing  (fig.  132)  of  Mr.  Listen's 
celebrated  case  of  Mrs.  Frazer,  from  whom  that  eminent 
surgeon   successfully  removed    the   growth.     The  tumour  is 


264      NON-MALIGNANT    TUMOURS  OF    UPPER   JAW. 


preserved  in  the  Museum  of  the  College  of  Surgeons  (2241), 
and  its  diameters  are,  vertically,  seven  inclies  ;  transversely, 
seven  inches  ;  from  before  backwards,  nearly  six  inches.  Con- 
trary to  the  ordinary  practice,  a  portion  of  the  integument 
was  removed  with  the  tumour,  measuring  twelve  inches  in 
length  and  ten  in  breadth,  and  this  left  a  gap  in  the  skin 
of  the  face  upon  the  patient's  recovery,  a  point  which  will 
be  again  referred  to.  The  growth  of  this  tumour  was 
connected  apparently  in  a  curious  way  with  the  performance 
of  the  uterine  functions.  The  patient  was  forty  years  old, 
and  the  tumour  began  to  grow  six  years  before  its  removal, 
in  consequence  of  a  blow  in  the  region  of  the  antrum.      Its 

Fig.  ]3'2. 


progress  at  first  was  slow  and  not  painful,  but  at  the  end  of 
two  years  a  distinct  tumour  was  felt  in  the  cheek.  During 
the  next  two  years  it  grew  rapidly,  especially  during  a  period 
of  gestation,  but  still  without  much  pain.  In  the  fifth  year 
of  its  growth  she  bore  a  second  child,  after  which  the  cata- 
menia  ceased  to  flow,  and  the  tumour  was  subject  to  monthly 
augmentations  of  its  vascularity,  and   slight    haemorrhages 


FIBROMA    OF   THE   UPPER   JAW.  265 

occurred  from  its  inner,  though  not  ulcerated,  surface,  and 
from  the  adjacent  parts  of  the  gum.  The  case  is  given  in 
detail  in  Mr.  Listen's  paper  already  referred  to, 

A  remarkable  feature,  noticed  in  a  case  of  fibrous  tumour 
of  the  antrum,  in  a  young  man  of  eighteen,  under  the  care 
of  Sir  J.  Paget,  in  1860,  was  a  distinct  pulsation  in  a  portion 
of  the  tumour  which  projected  into  the  orbit.  The  pulsa- 
tion was  slight  but  decided,  and  was  synchronous  Avith  the 
radial  pulse.  The  case  was  clearly  not  one  of  malignant 
disease,  but  proved  to  be  an  ordinary  fibrous  tumour  upon 
removal.  No  satisfactory  explanation  seems  possible  of  the 
case,  which  I  believe  to  be  unique.  Suppm^ation  has  oc- 
curred in  connection  with  fibrous  tumours  of  the  jaw,  but 
only,  I  believe,  when  they  have  been  punctured  with  a  view 
to  exploration  and  diagnosis.  Of  this  the  tumour  removed 
from  Janet  Campbell  and  preserved  in  the  Museum  of  the 
College  of  Surgeons  (2239),  is  an  example.  Simple  fibrous 
tumours  occasionally  recur  after  removal,  but  it  is  doubtful 
whether  in  these  cases  the  whole  of  the  disease  has  been 
eradicated.  According  to  0.  Weber  they  are  usually  con- 
nected with  the  lining  of  the  Haversian  canals  of  the  sur- 
rounding bone,  and  though  he  believes  that  these  processes 
may  sometimes  be  effectually  detached,  he  advises  the  prac- 
tice ordinarily  followed  of  removing  a  portion  of  bone. 

I  think  it  right  to  mention  here  that  all  the  specimens 
removed  by  Mr.  Liston,  and  referred  to  in  the  foregoing 
pages,  have,  in  the  new  catalogue  of  the  College  of  Surgeons' 
Museum,  been  placed  among  the  sarcomata,  on  what  I  cannot 
but  regard  as  insufficient  grounds.  In  the  first  place,  forty 
years'  soaking  in  spirit  prevents  anything  like  a  reliable 
microscopic  examination,  and  the  presence  of  a  few  cells 
scattered  among  the  fibres  of  a  tumour  are  no  proof  that  it 
is  not  a  fibrous  tumour ;  and,  secondly,  the  clinical  history 
of  all  these  cases  is  that  of  a  simple  growth,  which  once 
removed  did  not  recur.  I  have  therefore  included  them 
among  the  fibrous  tumours,  and  if  they  are  not  so,  it  is  very 
remarkable  that  there  is  no  specimen  of  the  true  fibrous 
tumour  of  tlie  upper  jaw  among  tlie  large  number  removed 


266       NON-MALIGNANT    TUMOURS    OF    UPPER   JAW. 

by  Listen  and  preserved  in  the  College  of  Surgeons'  and  in 
University  College  Museums. 

Fibrous  tumours  of  the  jaw,  like  those  in  other  parts  of 
the  body,  and  especially  in  the  uterus,  are  liable  to  calca- 
reous degeneration,  or,  as  is  sometimes  incorrectly  stated, 
to  ossific  deposit.  A  good  specimen  of  the  kind  is  preserved 
in  the  Museum  of  St.  Thomas's  Hospital  (I.  18),  which  is 
thus  described  in  the  Museum  catalogue  : — 

"  An  osteo-fibrous  tumour  of  the  .  antrum,  removed  by 
Mr.  Solly.  The  tumour  entirely  filled  the  cavity  of  the 
antrum,  the  bony  parietes  of  which  have  been  absorbed  to 
a  considerable  extent ;  it  protruded  the  cheek  anteriorly, 
projected  into  the  fauces  posteriorly,  pressed  down  the 
palate  inferiorly,  and  extended  to  the  septum  nasi  inter- 
nally. Its  firmest  point  of  attachment  is  to  that  part  of 
the  antrum  corresponding  to  the  roots  of  the  first  molar, 
canine,  and  incisor  teeth.  The  tumour  is  of  a  rounded  form, 
and  has  a  smooth  external  surface ;  its  section  presents  very 
much  the  appearance  of  a  fibrous  tumour  of  the  uterus  of 
slow  growth,  and  contains  an  abundance  of  bony  deposit. 

"  From  a  boy,  aged  seventeen.  The  existence  of  the  tumour 
was  discovered  only  ten  months  previous  to  its  removal, 
when  the  face  began  to  swell,  the  swelling  being  accompanied 
by  pain.  No  untoward  circumstances  followed  the  opera- 
tion, and  the  boy  left  the  hospital  quite  well.  The  deformity 
was  very  slight.  Five  years  after  the  ojDeration  the  boy  was 
in  capital  health."  More  complete  details  of  the  case  will 
be  found  in  Mr.  Solly's  "  Surgical  Experiences,"  lecture  41. 

A  thin  section  of  this  tumour  has  been  dried  and  pre- 
served, in  order  to  show  the  amount  and  distribution  of  the 
calcareous  matter  (I.  19). 

A  remarkable  example  of  calcareous  degeneration  of  a 
fibrous  tumour  occurred  in  the  practice  of  Sir  W.  Fergusson, 
and  the  preparation  is  now  in  the  Museum  of  the  College  of 
Surgeons  (2242).  It  is  a  fibrous  tumour  of  the  left  upper 
jaw,  of  some  years'  growtli,  from  a  woman  aged  fifty,  con- 
taining numerous  calcareous  particles  and  acicular  crystals, 
and  in  addition,  enclosing  a  suppurating  cavity,  in  which  was 


FIBROMA    OF   THE    UPPER   JAW.  267 

a  mass  about  an  inch  in  diameter,  found  by  Dr.  Goodhart 
to  consist  of  acicular  crystals  of  mineral  matter,  entangling 
in  places  nucleated  and  shrivelled  cells.  This  is  clearly  an 
example  of  extreme  calcareous  degeneration  undergoing 
necrosis. 

With  regard  to  the  causes  giving  rise  to  fibrous  tumours 
of  the  upper  jaw  there  is  much  obscurity,  though  there  is 
little  doubt  that  they  in  many  cases  originate  in  some  irri- 
tation due  either  to  a  blow,  or  more  frequently  to  the 
presence  of  decayed  teeth  ;  and  the  latter  may  give  rise  to 
a  tumour  commencing  in  the  alveolus  itself  or  within  the 
antrum,  the  lining  membrane  of  which  is  irritated  by  the 
fangs  of  the  diseased  teeth.  Bordenave  strongly  insisted 
upon  this,  and  since  his  time  most  surgeons  have  taken  the 
same  view.  Stanley  mentions  a  case  which  occurred  to  Mr. 
Luke,  in  which  a  black,  carious  tooth  was  found  imbedded 
in  a  fibrous  tumour  of  the  upper  jaw^  and  other  cases  of  the 
kind  have  occmTcd,  although  the  event  is  more  common  in 
the  case  of  the  lower  jaw. 

Since  the  publication  of  the  first  edition  of  this  work 
M.  Broca,  in  his  "Traite  des  Tumeurs"  (Paris,  1869),  put 
forward  the  view  that  many  cases  of  fibrous  and  fibro- 
cellular  tumour  of  both  upper  and  lower  jaw  depend  upon 
the  growth  of  a  tooth-germ,  and  these  are  included  by  him 
under  the  head  of  odontomcs  emhryo-plastiques.  There  is 
no  difference  in  structure  by  which  these  fibrous  odonto- 
mata  can  be  distinguished  from  the  ordinary  fibrous  tumour, 
but  according  to  M.  Broca  they  are  always  encysted,  and 
they  occur  only  in  young  subjects,  and  before  the  last  tooth 
is  formed.  Owing  to  their  ready  enucleation,  these  tumours 
show  no  tendency  to  recur.  I  have  met  with  but  one  case 
which  seemed  in  any  way  to  support  the  views  above  given. 
A  young  married  lady,  a  patient  of  Dr.  ISTeale,  had  a  tumour 
of  the  upper  jaw,  evidently  due  to  expansion  of  the  antrum, 
the  walls  of  which  crackled  under  pressure.  Believing  the 
swelling  to  be  due  to  fluid,  I  punctured  it,  giving  exit  to 
only  a  small  quantity  of  fluid,  and  discovered  a  tumour 
within.     On  laying  open  the  antrum,  I  was  able  to  enucleate 


268       NON-MALIGNANT   TUMOURS    OF    UPPER   JAW. 

with  the  finger  a  tuniour  which  had  very  slight  attach- 
ments, presented  all  the  appearance  of  a  fibroma,  and 
on  examination  by  Dr.  Bastian,  was  pronounced  to  be  very 
rich  in  cell  elements,  and  therefore  likely  to  recur.  Never- 
theless, the  patient  is  now  in  perfect  health,  fourteen  years 
after  the  operation. 

Enchondroma  of  the  upper  jaw  is  of  uncommon  occur- 
rence, but  the  jaw  may  become  involved  in  cartilaginous 
tumours  springing  from  other  bones  of  the  face.  Of  this 
there  is  an  example  in  St.  George's  Hospital  Museum 
(XVII,  66),  taken  from  a  young  woman,  who,  seven  years 
before  her  death,  began  to  suffer  from  soft  elastic  tumours 
on  the  inner  side  of  the  orbits.  Two  years  after,  the  right 
maxillary  bone  was  fuller  below  the  orbit  than  the  left,  and 
the  right  half  of  the  bony  palate  w^as  larger  and  more  de- 
pressed than  the  other  ;  but  in  neither  of  these  parts  was 
there  any  softening.  Gradually  the  eyeballs  were  protruded, 
and  the  siglit  was  lost.  Two  years  later,  it  was  noticed  that 
the  superior  maxillary  Ijones  projected  nearly  an  inch  beyond 
the  inferior,  so  that  she  had  some  difficulty  in  masticating.  A 
portrait  of  this  patient  is  preserved  in  St,  George's  Museum. 
The  tumour  was  found  to  project  into  the  cranium,  the  orbits, 
the  antra,  and  the  nasal,  zygomatic,  and  pterygo-maxillary 
fossse.  All  the  fossa?  were  quite  filled  up  by  the  growth,  and 
the  bones  of  the  face  and  orbits  extensively  absorbed.  The 
hard  palate  was  pressed  downwards,  so  that  the  teeth  on  the 
two  sides  deviated  from  their  natural  line,  and  the  left 
central  incisor  crossed  that  of  the  right  side.  Microsco- 
pical examination  of  the  tumour  showed  it  to  be  composed 
jjrincipally  of  cartilage.  A  full  description,  with  a  litho- 
graph of  the  preparation,  will  be  found  in  tlie  Fatholoyical 
Society  s  Transactions,  vol.  x. 

In  the  Museum  of  St.  Bartholomew's  Hospital  is  another 
post-mortem  specimen  of  cartilaginous  tumour  of  the  face, 
from  a  lad  of  sixteen  (XII.  1773),  occupying  the  situation  of 
the  superior  maxillary  bones,  which  are  completely  absorbed. 
Above,  the  tumour  has  extended  through  the  left  side  of  the 
base  of  the  skull  into  its  cavity,  wliere  it  forms  a  large  pro- 


ENCHONDROMA    OF    THE    UPPER   JAW.  269 

jection  in  the  situation  of  the  anterior  lobes  of  the  cerebrum  ; 
below,  it  is  united  to  the  soft  palate ;  in  front,  it  protrudes 
and  distends  the  left  nostril,  and  has  caused  the  ulceration 
of  a  part  of  the  integuments  of  the  face.  The  outer  surface 
of  the  tumour  is  nodulated,  its  interior,  shown  by  the  sec- 
tion, is  formed  of  close-set  nodules  and  masses  of  cartilage, 
partially  and  irregularly  ossified,  and  in  some  parts  inter- 
sected by  layers  of  a  softer,  probably  fibrous  tissue.  A  por- 
tion of  its  external  surface  projecting  below  the  left  nostril 
has  sloughed.  This  case  is  drawn  in  Mr.  Stanley's  illustra- 
tions to  his  work  on  "  Diseases  of  the  Bones  ;"  and  both  it 
and  the  preceding  preparation  illustrate  very  well  the  ten- 
dency of  cartilaginous  tumours  to  invade  all  the  surrounding 
structures,  and  to  fill  the  several  cavities. 

A  remarkable  case  of  recurrent  cartilaginous  tumour  of  the 
face,  originating  in  the  upper  jaw,  was  under  my  own  care, 
of  which  the  following  are  the  particulars : — The  patient, 
aged  thirty-four,  was  admitted  into  University  College  ■ 
Hospital  on  the  1st  of  January,  1868,  with  a  large  tumour 
of  the  right  side  of  the  face.  When  about  seventeen  years 
of  age  he  noticed  a  pimple  on  the  right  side  of  the  nose, 
which  increased  pretty  rapidly,  and  three  months  after 
(1851)  he  went  into  St.  Thomas's  Hospital,  when  Mr.  Le 
Gros  Clark  operated,  and  removed  a  tumour  as  large  as  a 
walnut.  He  quite  recovered,  and  was  well  for  a  iew  months, 
but  within  a  year  the  tumour  had  returned.  He  was  then 
admitted  into  King's  College  Hospital,  under  Mr.  Partridge, 
who,  in  June,  1852,  removed  the  tumour,  which  was  of  an 
osteo-cartilaginous  character,  oblong  in  shape,  and  of  the 
size  of  a  large  walnut,  projecting  slightly  into  the  antrum, 
and  involving  the  nasal  process  of  the  superior  maxillary 
bone,  but  in  no  way  implicating  the  mouth  or  orbit.  From 
this  operation  the  patient  made  a  good  recovery,  except  that 
a  small  fistulous  opening  was  left  in  the  cheek.  The  man 
continued  in  good  health  until  1857,  when  he  went  to 
America,  and  soon  after  arriving  there  he  found  the  tumour 
beginning  to  appear  again,  and  in  1860  Professor  Gunn 
operated  at  Anne  Harbour,  in  the  state  of  Michigan,  and 


270      XON-MALIGNANT   TUMOURS   OF   UPPER   JAW. 

removed  the  entire  rij^lit  upper  jaw.  The  tumour,  however, 
began  to  grow  again  rapidly,  and  projected  on  the  face.  The 
surgeons  at  Maple  Eapids,  where  he  lived,  wanted  to  operate 
again,  but  the  patient  declined,  and  returned  to  England  in 
1865.  Soon  after  this  an  abscess  formed  in  tlie  upper  part 
of  the  tumour,  which  was  lanced  with  great  relief,  but  the 
incision  thus  made  had  never  closed,  owing  to  the  stretching 
of  the  skin  by  the  tumour. 

The  patient's  appearance  on  admission  was  most  unsightly 
(fig.  133),  the  riglit  side  of  the  face  being  greatly  disfigured 
by  a  large  tumour,  by  which  the  eye  was  thrust  completely 

Fig.  133. 


aside,  but  without  loss  of  vision.  Immediately  to  the  inner 
side  of  the  eye  was  an  open  granulating  sore  of  the  size  of 
a  florin,  the  result  of  the  incision  for  the  evacuation  of  matter 
already  referred  to.  The  tumour  appeared  externally  to  con- 
sist of  two  portions,  separated  by  a  horizontal  sulcus,  at  the 
bottom  of  which  the  fistulous  opening  resulting  from  the 
second  operation  was  still  visible.  The  upper,  and  more 
prominent  portion   had  invaded   the   orbit,  reaching  to  its 


ENCHONDROMA   OF   THE    UPPER   JAW.  271 

upper  border,  aud  extending  beyond  the  middle  line  of  the 
nose.  A  small  portion  of  this  had,  within  the  previous  two 
months,  projected  through  the  left  nasal  bone.  The  lower 
portion  of  the  tumour  involved  the  ala  of  the  nose  and 
adjacent  portion  of  the  cheek,  both  of  which  were  much 
distorted  ;  on  a  small  projecting  portion  of  this  the  skin 
was  adherent.  Both  nostrils  were  completely  blocked,  and 
had  been  so  for  months.  Within  the  mouth  it  was  seen 
that  the  whole  of  the  right  side  of  the  hard  palate  had  been 
removed ;  and  in  its  place  there  was  a  smooth,  red,  oval  mass, 
coming  down  to  the  level  of  the  teeth  of  the  opposite  side. 
The  scars  in  the  middle  line  of  the  lip  and  on  the  cheek, 
resulting  from  former  operations,  were  still  visible.  The 
tumour  was  solid  and  not  tender  to  the  touch,  the  most 
prominent  point  being  apparently  osseous.  There  was  no 
enlargement  of  the  glands  in  the  neck  or  elsewhere,  and  the 
man  appeared  in  good  health.  The  tumour  had  made 
decided  progress  within  the  previous  few  months,  and  he 
was  anxious  to  have  it  removed,  to  which,  after  a  consulta- 
tion with  my  colleagues,  I  agreed. 

On  January  8,  under  chloroform,  I  made  a  curved  in- 
cision below  the  eye  to  the  side  of  the  nose,  from  the 
extremity  of  which  a  vertical  incision  was  carried  down  the 
face  and  round  the  ala  of  the  nose ;  and  the  lip  was  divided 
in  the  cicatrix  of  a  former  operation.  The  flap  was  then 
dissected  back,  and  with  it  a  hard  prominent  nodule  of  bone, 
which  became  detached  from  the  bulk  of  the  tumour.  The 
tumour  being  thus  exposed,  I  proceeded  to  enucleate  it  with 
the  fingers,  and  by  successive  efforts  removed  in  this  way  the 
upper  part  of  the  growth.  The  portion  projecting  into  the 
mouth  was  found  to  be  held  by  a  firm  band  of  tissue  in  the 
position  of  the  gum,  and  after  dividing  this  I  was  able  to 
tear  out  the  growth,  and  also  a  portion  projecting  through 
the  posterior  nares  into  the  pharynx.  The  wound  having 
been  well  sponged  out  and  the  haemorrhage  having  abated, 
the  portion  at  the  inner  side  of  the  orbit  was  removed,  and 
was  found  to  project  into  the  frontal  sinuses,  which  (parti- 
cularly the  right)  were  considerably  expanded.    With  one  of 


272      NON-MALIGNANT  TUMOURS    OF    UPPER    JAW. 

Langenbeck's  palate  spatiilfe  I  carefully  cleared  these  out, 
scraping  tlie  walls,  and  then  introduced  a  pledget  of  lint 
covered  with  a  paste  of  chloride  of  zinc  (to  which  a  string 
was  attached),  in  order  to  destroy  any  remaining  portion. 
This  was  the  only  part  from  which  the  growth  appeared  to 
have  arisen,  the  remainder  of  the  huge  cavity  left  iDy  the 
removal  of  the  growth  being  perfectly  smooth  and  healthy. 
The  septum  narium  was  found  to  be  completely  pushed  over 
to  the  left,  and  to  have  been  destroyed  at  the  upper  part  by 
a  projecting  lobule  of  the  growth,  which  had  pushed  through 
the  nasal  bone.  The  ala  of  the  nose  included  a  small  portion 
of  the  growth,  which  was  removed,  and  also  the  bony  nodule 
attached  to  the  flap,  the  upper  corner  of  which,  being  very 
thin  and  closely  involved  in  the  growth,  was  cut  off.  The 
wound  was  sponged  out  with  solution  of  chloride  of  zinc, 
and  all  hsemorrhage  having  ceased  without  the  application 
of  any  ligatures,  the  lip  was  brought  together  with  hare-lip 
pins,  and  the  remainder  of  the  wound  with  wire  sutures. 
The  edges  of  the  gap  caused  by  the  opening  of  an  abscess 
some  months  back  were  brought  together,  but  finding  that 
this  prevented  the  patient  closing  his  eye,  I  subsequently 
removed  these  sutures.  Collodion  was  painted  over  the 
wound,  and  the  patient,  who  had  a  good  pulse,  was  carried 
to  bed. 

The  patient  made  an  uninterruptedly  good  recovery  from 
the  operation.  The  wound  was  kept  clean  by  syringing 
with  Condy's  fluid  ;  the  plug  of  lint  in  the  frontal  sinus  was 
removed  on  the  third  day  after  the  operation,  and  the 
sutures  on  the  eighth  day,  the  incision  being  well  united. 
The  right  eye,  which  had  been  much  displaced,  began 
gradually  to  recover  its  proper  position.  A  fortnight  after 
the  operation,  the  patient  was  up  and  about  the  ward,  and 
on  Feb.  1  he  went  out  for  a  walk.  On  Sunday,  Feb.  2, 
he  again  went  out,  the  house-surgeon  not  being  aware  that 
there  was  a  bitter  east  wind.  This  he  felt  a  good  deal,  and 
the  next  day  his  face  was  noticed  to  be  swollen  and  red. 
This  had  increased  on  the  follo\ving  day,  when  I  saw  him, 
and  it  was  evident  that  an  attack  of  erysipelas  was  coming 


ENCHONDROMA   OF  THE  UPPEH  JAW.  273 

on.  The  patient  was  at  once  placed  in  a  separate  ward,  and 
active  treatment  adopted.  The  erysipelas  spread,  however,- 
and  affected  the  throat,  so  that  on  Feb.  7  he  was  able  to 
swallow  but  little,  and  was  becoming  rapidly  exhausted.  By 
the  frequent  use  of  the  stomach-pump  nourishment  was 
introduced  into  the  stomach,  and  he  rallied  for  a  day  or  two. 
Symptoms  of  pyaemia,  however,  now  manifested  themselves, 
and  the  patient  rapidly  lost  ground,  and  after  lingering  for 
a  week,  died  on  Feb.  17. 

At  the  post-mortem  examination^  the  incisions  in  the  face 
were  cicatrized ;  but  the  site  of  the  tumour  was  granulating, 
and  encrusted  mth  mucus  in  parts.  On  removing  the 
brain,  it  and  the  membranes  were  found  perfectly  healthy  ; 
but  the  plate  of  bone  between  the  frontal  sinus  and  the 
cranial  cavity  was  so  thin,  that  it  broke  in  the  removal  of 
the  brain.  There  was  no  appearance  of  any  remnant  of 
tumour  either  in  the  frontal  sinus  or  elsewhere,  the  walls  of 
the  large  cavity  left  by  its  removal  being  healthy.  In  the 
thorax  there  was  abundant  evidence  of  pysemia,  the  lungs 
being  filled  with  pysemic  abscesses.  The  tumour  weighed 
nine  ounces,  and  consisted  of  a  loose  cartilaginous  material 
enclosed  in  a  bony  cyst,  from  which  spicula  were  sent  into 
the  interior.  At  two  points,  and  particularly  at  the  most 
prominent  portion  of  the  tumour,  the  bone  was  of  con- 
siderable thickness.  The  tumour  was  exhibited  at  the 
Pathological  Society,  and  was  referred  to  a  committee  of 
investigation,  which  pronounced  it  to  be  an  enchondroma 
undergoing  ossification,  and  presented  the  following  report 
upon  it :-— "  The  portions  examined  consisted  of  a  thin 
incomplete  bony  shell,  coated  by  a  fibrous  membrane,  and 
enclosing  a  soft  tissue  penetrated  by  bony  spicula.  The 
external  membrane  is  composed  of  wavy  bundles  of  common 
connective  tissue,  interwoven  in  planes  generally  parallel  to 
the  surface  of  the  underlying  bone,  and  enclosing  groups  of 
fat  cells.  Beneath  this  outer  stratum  there  is  a  deeper 
layer,  immediately  resting  upon  the  bone,  composed  chiefly 
of  small,  closely-packed  cells,  evidently  the  equivalent  of  the 
■  osteogenic  layer  of  periosteum,  and  ministering  as  this  does 

T 


274      NON-MALIGNANT   TUMOURS   OF   UPPER   JAW. 

to  the  growth  of  the  bony  shell  This  latter  is  lamellated 
parallel  to  its  outer  surface,  and  it  has  a  true  osseous  struc- 
ture. The  enclosed  soft  tissue  consists  in  greatest  part  of 
cartilage,  the  characters  of  which,  though  varying  consider- 
ably, are  everywhere  unmistakable.  The  cartilage  capsules 
in  some  situations  are  very  large,  and  so  crowded  as  nearly 
to  exclude  the  intercellular  substance,  approximating  to  a 
colloid  structure ;  while  in  other  parts  the  two  tissues  exist 
in  nearly  equal  quantities,  and  here  many  of  the  capsules 
exhibit  the  concentric  rings  indicative  of  successive  layers, 
which  are  not  uncommonly  seen  in  old  and  slow-growing 
enchondromata.  The  tumour  belongs,  no  doubt,  to  the 
category  of  enchondromata." 

Probably  the  largest  enchondroma  -of  the  upper  jaw  ever 
submitted  to  operation  is  one  recorded  by  Mr.  O'Shaugh- 
nessy,  in  his  essay  on  Diseases  of  the  Jaws  (1844).  The 
patient  was  a  Hindoo,  aged  twenty-one,  who  had  a  tumour 
of  the  upper  jaw,  of  a  year's  growth  (?)  which  had  attained 
an  enormous  size,  as  shown  in  the  illustrations  of  the  work 
in  question,  looking  nearly  as  big  as  the  patient's  head. 
Mr.  O'Shaughnessy  removed  the  tumour,  which  weighed 
four  pounds,  and  was  nearly  globular  in  form,  having 
at  its  inferior  surface  a  deep  groove  into  which  the  lower 
jaw  sank.  On  section  it  proved  to  be  of  dense  fibro-carti- 
laginous  structure,  surrounded  by  a  thin  shell  of  bone 
in  the  greater  part  of  its  extent.  The  patient  made  a  good 
recovery. 

These  cases  will  serve  to  illustrate  the  leading  features 
with  regard  to  enchondroma.  The  disease  appears  ordina- 
rily early  in  life,  springing  from  the  surface  of  the  bone,  or 
from  the  antrum,  and  then  making  steady  progress  either 
externally,  as  in  the  last -mentioned  case,  or  internally,  as 
in  the  former  ones.  It  produces  absorption  of  the  bone  of 
the  maxillfc  in  its  progress,  and  protrudes  beneath  the  skin, 
which,  however,  it  rarely,  if  ever,  involves.  Its  rate  of  in- 
crease is  ordinarily  slow,  and  there  must,  I  fancy,  be  some 
error  in  the  statement  of  Mr.  O'Shaughnessy's  patient,  since 
it  is  difficult  to  imagine  that  a  growth  of  that  enormous  size 


ENCHONDROMA    OF    THE    UPPER   JAW.  275 

could  have  been  produced  in  one  year.  In  the  early  stage, 
the  enchondromatous  tumour  may  possibly  be  got  rid  of  by 
absorbent  applications ;  thus,  Mr.  Stanley  (p.  147)  mentions 
the  case  of  a  female,  aged  twenty-eight,  who  had  a  round 
tumour  of  the  size  of  a  hazel-nut  on  the  front  of  the  maxilla, 
which  had  been  growing  some  months.  This  was  ascer- 
tained, by  the  introduction  of  a  needle,  to  be  composed  of 
cartilage  with  particles  of  bone  dispersed  through  it.  Under 
the  local  use  of  iodine  two-thirds  of  the  growth  disappeared 
in  the  course  of  a  few  weeks. 

Such  a  result  cannot  be  hoped  for  when  the  tumour  has 
attained  any  size,  but  provided  it  is  still  confined  to  the 
maxilla,  a  cartilaginous  tumour  is  a  favourable  one  for  re- 
moval, owing  to  its  solidity  and  rounded  form,  and  the  ease 
with  which  it  is  isolated.  The  first  case  in  which  M. 
Gensoul  removed  the  superior  maxilla  was  for  a  tumour  of 
this  kind.  Ordinarily  perfect  immunity  from  return  is 
obtained,  provided  the  whole  disease  has  been  extirpated. 

In  many  cases  of  enchondroma  a  certain  amount  of  fibrous 
tissue  is  found  mixed  with  the  cartilage,  and  in  some  cases, 
particularly  those  of  slow  growth  and  of  long  standing,  the 
fibrous  has,  to  the  naked  eye,  almost  replaced  the  cartilagi- 
nous element.  Of  this  an  enchondromatous  tumour,  removed 
by  Mr.  Square,  of  Plymouth,  in  November,  1866,  and  kindly 
given  me  by  that  gentleman,  is  an  excellent  example. 

The  tumour  was  of  the  size  of  an  orange,  and  occupied 
the  right  superior  maxilla  of  a  woman,  aged  forty-seven. 
It  had  been  growing  ten  years,  and  Mr.  Square  successfully 
removed  it.  The  preparation,  now  in  the  Museum  of  the 
College  of  Surgeons  (2316),  and  of  which  a  section  has 
been  made,  shows  a  surface  closely  resembling  a  fibrous 
tumour,  but  in  which  cartilage  cells  are  readily  found  under 
the  microscope.  The  preparation  shows  a  deep  groove  in 
the  buccal  surface  of  the  tumour  caused  by  the  teeth  of  the 
lower  jaw. 

The  ossific  deposit,  beginning  at  several  separate  points, 
which  is  not  unfrequently  found  in  connection  with  enchon- 
dromata  of  other  parts   of    the    body,   may  take  place  in 

T  2 


276      NON-MALIGNANT   TUMOURS   OF   UPPER   JAW. 

enchondroma  of  the  upper  jaw.  A  very  excellent  example 
of  this  was  published  by  the  late  Mr.  Maurice  Collis,  of 
Dublin  (BuUin  Quarterly  Journal,  Aug.  1867),  and  the 
appearance  of  the  patient  is  well  shown  in  the  lithographic 
illustrations  which  accompany  that  paper.  The  patient  was 
fifty  years  of  age,  and  the  disease  dated  from  his  fourteenth 
year.  It  grew  slowly  at  first,  but  latterly  had  increased 
with  considerable  rapidity.  The  tumour  was  firm  and  hard, 
but  painless  until  recently,  when  brow-ague  was  complained 
of.  The  sight  of  the  left  eye  w^as  lost,  the  left  nostril 
occluded,  and  hearing  on  that  side  somewhat  dull.  The 
tumour  had  expanded  the  chei'-k,  pushed  up  the  floor  of  the 
orbit,  and  depressed  the  hard  palate,  Mr.  Collis  success- 
fully removed  the  growth,  and  the-  patient  made  a  rapid 
recovery.  The  following  is  Mr.  CoUis's  description  of  the 
tumour  : — 

"  Much  of  it^  posterior  part  was  removed  piecemeal,  but 
wliat  remained  was  composed  of  two  kinds  of  bone.  The 
centre,  which  may  be  supposed  to  correspond  to  the  antrum, 
is  remarkal^ly  hard  and  close — white,  with  fine  concentric 
rings,  like  ivory,  which  it  also  resembled  not  a  little  in  its 
hardness.  All  round  this,  except  above,  lay  a  much  larger 
mass  of  bone,  distinctly  and  coarsely  laminated,  softer  in 
texture,  and  enveloped  in  a  very  thin  and  strong  layer  of 
hard  bone.  This  external  mass  was  divided  into  two  by  a 
fissure  which  ran  in  an  oblique  curve  upwards  and  outwards 
into  a  very  small,  irregular  space,  filled  with  a  mass  of 
lining  membrane,  gathered  up  and  jammed  together.  These 
two  masses  evidently  corresponded  to  the  middle  and  inferior 
spongy  bones  ;  and  the  fissure  and  cavity  represented  that 
portion  of  the  nostril  which  normally  lies  between  these  two 
bones.  The  growth  commenced  in  the  antrum,  filled  it, 
implicated  its  walls,  extended  to  the  spongy  bones,  develo2)ing 
itself  layer  over  layer,  until  the  entire  nasal  cavity  was  filled. 
It  then  continued  to  grow,  producing  the  immense  deformity 
already  described.  Originally  it  had  probably  been  an  en- 
chondroma, but  as  years  advanced  it  ossified,  beginning 
iroju  the  centre.     The  outer  layers  of  the  new  growth  were 


OSTEOMA  OF  THE  UPPER  JAW,  277 

probably  the  most  recent,  as  they  contained  some  fragments 
of  imperfect  or  degenerate  cartilage.  The  whole  was  en- 
closed within  a  real  bony  layer,  derived  from  the  proper 
tissue  of  the  spongy  bones  and  of  the  walls  of  the  antrum." 

In  St.  Thomas's  Hospital  Museum  is  a  section  of  a  skull 
(C.  196),  showing  a  large  tumour  in  connection  with  the 
superior  maxilla,  which  appears  to  be  an  ossified  enchon- 
droma.  Superiorly  the  growth  encroaches  considerably  upon 
the  cavity  of  the  orbit,  and  posteriorly  it  fills  nearly  the 
whole  of  the  zygomatic  fossa,  extending  as  far  back  as  the 
glenoid  cavity.  On  the  inner  side  it  has  involved  the  upper 
part  of  the  nasal  and  the  lower  part  of  the  sphenoidal 
sinuses  ;  whilst  below  it  projects  through  the  hard  palate 
into  the  cavity  of  the  mouth. 

During  the  winter  session  of  1867-68,  my  colleague,  Mr. 
Beck,  then  Demonstrator  of  Anatomy  at  University  College, 
found  in  the  antrum  of  a  subject  an  osseous  mass  filling  up 
the  cavity  and  attached  to  its  outer  wall,  but  giving  rise  to 
no  external  tumour  either  on  the  face  or  in  the  nares.  On 
section  the  bone  was  white  and  dense,  and  upon  microscopic 
examination  the  late  Mr.  Bruce  considered  it  to  be  an 
instance  of  ossified  encbondroma,  the  calcareous  matter  being 
more  granular  than  in  ordinary  osseous  growths,  and  the 
lacunae  and  canaliculi  imperfectly  developed.  The  prepara- 
tion is  in  my  possession^  and  will  serve  to  elucidate  some 
points  in  connection  with  osseous  tumours  to  be  subsequently 
referred  to. 

Osteoma. — The  simplest  form  of  osseous  tumour  of  the 
upper  jaw  is  an  hypertrophy  of  the  whole  or  of  some  portion 
of  the  bone.  A  case  of  Sir  William  Fergnsson's  has  already 
been  referred  to  (p.  216),  in  which  this  result  was  due  to  the 
presence  of  a  tooth  imbedded  in  the  jaw ;  but  the  same  thing 
may  happen  without  obvious  cause.  The  tumour  is  slow  of 
growth  and  painless,  and  upon  removal  shows  no  deviation 
from  the  ordinary  structure  of  healthy  bone.  An  example 
occurring  in  a  girl  of  sixteen,  from  whom  Sir  William 
Fergusson  successfully  removed  a  growth  of  the  kind,  will  be 
found  in  the  Lancet,  July  26,  1856 


27 S      NON-MALIGNANT   TUMOURS   OF   UPPER   JAW. 


In  October,  1883,  I  had  under  my  care  in  University 
College  Hospital,  a  young  woman,  aged  twenty-five,  in  whom 
a  painless  enlargement  of  the  right  upper  jaw  had  been 
noticed  for  ten  years,  encroaching  upon  the  palate  and 
bulging  out  the  cheek,  I  successfully  removed  the  whole 
upper  jaw,  and  on  section  the  tumour  was  found  to  be 
simple  bone,  very  dense,  but  otherwise  healthy.  One  half 
of  the  specimen  is  in  University  College  and  the  other 
in  the  College  of  Surgeons'  Museum. 

In  the  Museum  of  Charing  Cross  Hospital  is  a  remarkable 
specimen  of  osseous  tumour  of  the  upper  jaw,  removed  by 
Mr.  Hancock.  The  whole  jaw  seems  expanded  anteriorly, 
and  the  outer  compact  plate  is  perfect,  except  at  the  part 
immediately  below  the  infra-orbital  .foramen,  where  it  has 
given  way,  and  the  cancellous  structure  forming  the  interior 
of  the  tumour  is  seen.  Mr.  Hancock,  in  referring  to  this 
specimen  {Lancet,  Jan,  13,  1855),  specially  calls  attention  to 
the  fact  that  the  bone  yielded  to  pressure  to  such  an  extent 
as  to  lead  to  some  doubt  as  to  its  osseous  nature. 

A  still  more  remarkable  specimen  of  the  same  .kind  is 
preserved  in  the  Musee  Dupuytren  at  Paris,  which  is  shown 
in    fius.    134    and 


Fig.  134. 


135    from  the    "Traite    de    Pathologic 
Fig.  135. 


Externe,"  by  M.  Vidal  de  Cassis.      It  is  connected  with  the 
left  superior  maxilla,  being  limited  internally  by  the  inter- 


OSTEOMA    OF    THE    UPPER   JAW.  279 

maxillary  suture,  behind  by  the  pterygoid  process,  above 
and  externally  by  the  malar  bone.  The  tumour  encroaches 
considerably  upon  the  cavity  of  the  mouth,  and  reaches  back 
as  far  as  the  front  of  the  spine.  Its  form  is  bi-lobed,  and 
in  the  deep  sulcus  between  the  lobes  can  be  seen  a  molar 
tooth.  All  the  other  teeth  of  the  jaw  have  disappeared, 
and  there  is  no  trace  of  their  alveoli.  The  left  orbit  and 
nasal  fossa  are  not  sensibly  diminished  in  size,  but  the  cavity 
of  the  mouth  is  almost  entirely  occupied  by  the  posterior 
lobe  of  the  tumour.  The  lower  jaw  has,  in  this  case,  under- 
gone several  remarkable  alterations.  It  must  at  first  have 
pressed  upon  the  growth  and  produced  the  deep  sulcus  be- 
tween the  lobes,  but  in  its  turn  the  tumour  has  reacted 
upon  the  lower  jaw  with  the  following  effect : — It  has  caused 
a  double  luxation  of  the  jaw,  the  left  condyle  resting  against 
the  root  of  the  zygoma  and  the  glenoid  cavity  being  filled 
with  soft  material.  The  teeth  of  the  left  side  of  the  lower 
jaw  have  disappeared,  and  absorption  of  part  of  the  coronoid 
process  and  the  whole  of  the  alveolus  has  taken  place,  so 
that  only  the  base  of  this  part  of  the  bone  is  left.  The 
outer  surface  of  the  tumour  is  smooth,  and  presents  nume- 
rous vascular  grooves  of  good  size ;  at  many  points  it  is  per- 
forated with  holes.  The  vascularity  of  the  other  bones  of 
the  face  does  not  appear  augmented. 

In  the  Museum  of  Netley  Hospital,  wliich  includes  the 
preparations  formerly  at  Fort  Pitt,  Chatham,  there  is  a 
specimen  of  large  osseous  tumour  of  the  upper  jaw  closely 
resembling  that  last  described,  but  of  smaller  size. 

Besides  this  form  of  bony  tumour,  due  apparently  to  an 
increase  of  the  cancellous  structure  of  the  bone,  specimens 
of  tumour  as  hard  as  ivory  have  from  time  to  time  been 
met  with.  Perhaps  the  most  remarkable  of  these  is  one 
described  by  Mr.  Hilton,  in  the  Guys  Sosintal  Bcports, 
vol.  i.  p.  493,  from  the  fact  that  the  tumour  separated  spon- 
taneously from  the  face.  The  patient  was  a  man  aged 
thirty-six,  who,  twenty-three  years  before  Mr.  Hilton  saw 
him,  noticed  a  pimple  below  the  left  eye,  close  to  the  nose, 
which  he  irritated,  and  from  that  spot  the  tumour  appears 


280      NON-MALIGNANT   TUMOURS   OF   UPPER   JAW. 

to  have  originated.  The  tumour  in  its  growth  displaced 
the  eyeball,  giving  rise  to  excruciating  pain,  which  subsided 
on  the  bursting  of  the  ball.  It  began  to  loosen  by  a  process 
of  ulceration  around  its  margin  six  years  before  it  fell  out, 
which  event  was  unattended  by  either  bleeding  or  pain.  The 
tumour  weighed  14|  ounces.  It  was  tuberculated  exter- 
nally, and  an  irregular  cavity  existed  at  the  posterior  part. 
A  section  presented  a  very  hard  polished  surface  resembling 
ivory,  and  exhibited  lines  in  concentric  curves  enlarging  as 
they  were  traced  from  the  posterior  part,  The  huge  cavity 
left  by  the  tumour  was  bounded  below  by  the  floor  of  the 
nose  and  antrum,  above  by  the  frontal  and  ethmoid  bones, 
internally  by  the  septum  nasi,  and  externally  by  the  orbit, 
which  had  been  considerably  encroached  upon  by  the 
tumour.  This  patient  was  alive  in  1865,  thirty  years  after 
the  prolapse  of  the  tumour. 

A  case  in  many  respects  resembling  Mr.  Hilton's  case 
was  under  the  care  of  Sir  William  Fergusson,  whom  I  had 
the  opportunity  of  seeing  operate  upon  it.  The  patient  was 
a  young  man  of  twenty-one,  who  had  first  noticed  the 
swelling  on  the  left  side  of  the  face  twelve  years  before.  It 
grew  for  six  or  seven  years,  and  then  remained  stationary. 
Two  years  before  he  had  consulted  a  quack,  who  attempted 
to  destroy  the  growth  with  caustic,  and  produced  the  large 
hole  seen  in  the  lower  part  of  the  tumour  (fig.  136). 

On  admission  into  King's  College  Hospital  there  was  a 
swelling  on  the  left  side  of  the  face  about  the  size  of  an 
apple,  extending  from  the  eyebrow  to  a  line  less  than  one 
inch  above  the  mouth.  Internally,  it  encroached  upon  the 
nose,  displacing  it  a  little,  the  nasal  bone  being  pushed  for- 
wards and  the  left  ala  ilattened  on  the  colunnia ;  the  mass 
was  felt  by  the  finger  in  the  mouth  above  the  gums.  The 
nostril  on  the  same  side  was  perfectly  blocked  up,  the  patient 
being  totally  unable  to  breathe  through  it.  The  right  nostril, 
however,  was  quite  free.  Outwards,  the  tumour  extended  to 
the  angle  of  the  orbit ;  the  arch  was,  however,  not  displaced, 
but  the  tumour  extended  slightly  above  it.  TJie  floor  of 
the  orbit  seemed  displaced.     The  eyeball  was  seen  imbedded 


OSTEOMA  OF   THE   UPPER   JAW.  281 

in  the  most  prominent  and  central  part  of  the  tumour,  and 
removed  more  than  an  inch  from  its  natural  position  in  the 
orbit,  which  was  entirely  blocked  up  by  the  mass.  There 
was  no  extension  into  the  pharynx.    The  tumour  was  every- 

FiG.  136. 


where  hard,  with  a  slight  blush  over  the  surface.  In  its 
centre  was  a  round  opening,  produced  by  the  caustic  applied 
two  years  previously,  of  about  the  size  of  a  shilling,  deep, 
and  displaying  in  its  floor  black  necrosed  bone,  and  dis- 
charging pus.  The  patient  said  he  had  suffered  neither 
headache  nor  pain  in  the  tumour  since  its  commencement, 
twelve  years  before,  and  that  his  sight  had  been  unaffected. 
Sir  William  Fergusson  operated  upon  this  patient  on  No- 
vember 30,  1867,  and  succeeded  in  removing  the  whole  of 
the  prominent  tumour,  weighing  10|  ounces,  which  consisted 
in  all  its  anterior  part  of  nodulated  bone  as  hard  as  ivory, 
and  posteriorly,  of  very  dense  ordinary  bone  mixed  with  a 
small  amount  of  cartilage.  A  section  showed  an  ivory-like 
mass  closely  resembling  Mr.  Hilton's  specimen,  connected 
with  a  mass  of  very  much  condensed  bone.  The  tumour 
sprang  apparently,  as  in  the  former  case,  from  the  upper 
part  of  the  maxilla,  and  had  invaded  the  antrum,  orbit,  and 


282      NON-MALIGNANT   TUMOURS    OF   UPPER   JAW. 

nostril.  The  palate  was  in  no  way  involved  in  the  growth, 
and  was  preserved  entire  at  the  operation.  Sir  William 
Fergusson  sawing  horizontally  immediately  above  it.  Un- 
fortunately the  patient  sank  rather  suddenly,  from  intiam- 
mation  of  the  lungs,  on  the  fourth  day. 

At  the  post-mortem  examination,  after  removal  of  the 
brain,  it  was  found  that  the  affection  of  the  bone  involved 
the  base  of  the  skull,  there  being  a  projection  of  the  size  of 
a  hazel-nut  from  the  sphenoid  near  the  optic  foramen.  This 
involved  the  foramen  and  extended  along  the  sphenoidal 
fissure,  the  optic,  third,  and  fourth  nerves  passing  through 
the  condensed  bone  of  which  it  was  composed.  The  brain 
was  unafiected  (vide  Lancet,  Feb.  8,  1868). 

This  specimen  was  exhibited  to  the  Pathological  Society 
of  London  and  was  reported  upon  by  a  committee.  The 
report  of  this  committee,  drawn  up  by  Mr.  Hulke,  which 
will  be  found  in  cxtenso  in  vol.  xix.  of  the  Pathological 
Transactions,  expresses  an  opinion  that  "  the  hard  part  of 
the  tumour  has  been  directly  formed  by  the  exogenous 
growth  of  successive  layei-s  of  dense  bony  tissue  under  the 
periosteum,  which  opim'on  is  confirmed  by  the  absence  from 
the  hard  tissue  of  the  regular  Haversian  systems  so  charac- 
teristic of  secondary  bone." 

The  reporters  "  did  not  find  anywhere  along  the  meeting 
line  of  the  hard  and  spongy  bony  tissues  anything  resem- 
bling cartilage,  and  are  disposed  to  regard  the  splitting  of 
the  tumour  along  this  line  as  the  result  of  violence,  the 
place  of  the  separation  being  determined  by  the  different 
resistances  of  the  two  kinds  of  bony  tissue.  The  intrusion 
of  masses  of  the  spongy  tissue  with  the  hard  along  the 
meeting  line,  and  the  occurrence  of  minute  specks  of  spongy 
tissue  in,  the  midst  of  the  hard  tissue,  suggest  the  direct 
continuity  of  the  two  tissues,  and  the  microscopic  appear- 
ances prove  not  only  that  this  actually  occurs,  but  also  that 
the  spongy  tissue  is  formed  by  the  rarefaction  of  the  hard. 
For  near  its  deep  limits  absorption  spaces  begin  to  appear 
in  the  hard  tissue,  and  these,  increasing  in  number  and  size 
and  coalescing,  produce  large  medullary  spaces  and  cancelli. 


OSTEOMA  OF  THE   UPPER  JAW.  283 

These  are  filled  with  a  soft  medulla  carrying  blood-vessels, 
and  their  walls  consist  of  remnants  of  the  hard  primary  bone 
and  of  new  lamelhe  formed  from  the  young  medulla." 

It  seems  to  me  difficult  to  imagine  that  the  condensed 
bone  which  extended  into  the  skull,  could  at  any  time 
have  been  of  an  ivory  nature,  as  this  report  implies.  Pre- 
suming the  ivory-like  growth  to  have  been  deposited  from  the 
periosteum  on  the  surface  of  the  original  maxilla,  it  is  con- 
ceivable that  the  same  action  which  led  to  this  result  may 
have  led  to  a  thickening  and  induration  of  the  subjacent 
bone,  which,  in  process  of  years,  by  simple  extension,  may 
have  reached  the  sphenoid  bone. 

In  both  these  cases  the  tumour  appears  to  have  taken  its 
origin  in  the  upper  wall  of  the  antrum  and  to  have  grown 
forwards ;  but  tumours  of  the  same  kind  have  been  found 
completely  within  the  superior  maxilla,  the  anterior  wall  of 
which  has  been  merely  expanded  by  the  growth  behind  it. 
Of  this,  two  cases  reported  within  the  last  few  years  by  M. 
Michon  and  Dr.  Duka  are  good  examples,  and  they  will 
be  elucidated  by  reference  to  a  case  recorded  by  M.  De- 
marquay. 

M.  Michon's  case  is  reported  in  the  2nd  volume  of  the 
Me'moires  de  la  Soci^t6  cU  Chirurgie  de  Pai-is  (1851) ;  his 
patient  being  a  man  of  nineteen,  who  had  a  large  tumour 
of  the  right  upper  jaw,  which  had  existed  for  three  years. 
The  tumour  was  rounded  and  hard,  and  had  pushed  up  the 
eyeball  considerably,  and  closed  the  right  nostril,  but  the 
palate  was  not  affected.  M.  Michon  operated  in  Jan.  1850, 
by  turning  up  a  triangular  flap  of  skin.  He  had  intended 
to  have  removed  the  entire  upper  jaw,  but  having  with  con- 
siderable, difficulty  removed  the  front  wall  of  the  antrum,  he 
found  the  tumour  lying  in  the  cavity,  and  connected  only 
with  the  floor  of  the  orbit  and  the  vomer.  After  an  opera- 
tion extending  over  an  hour  and  six  minutes,  and  without 
aneesthetics,  the  tumour  was  at  length  removed.  The  whole 
of  the  vomer  and  a  part  of  the  maxilla  came  away  with  the 
tumour,  which  was  a  flattened  sphere,  or  somewhat  resem- 
bled a  heart  in  shape.      It  weighed  120  grammes  (1,800 


284      NON-MALIGNANT   TUMOUKS   OF   UPPER   JAW. 

grains),  and  was  deeply  lobulated,  particularly  on  the  pos- 
terior aspect.  A  section  showed  concentric  markings  npon 
a  surface  of  ivory,  and  microscopic  examination  demon- 
strated the  lacuna}  and  canaliculi  of  true  bone.  The  patient 
made  a  good  recovery. 

Dr.  Duka's  case  is  reported  in  the  Pathological  Society's 
Transactions,  vol.  xvii.,  and  occurred  in  a  female  native  of 
Bengal,  aged  twenty-six,  and  on  the  right  side  of  the  face, 
which  was  not  much  deformed.  There  was  a  discharge  from 
the  right  nostril,  which  was  obstructed,  and  on  examination 
a  hard  tumour  was  found  within  it,  wJiich  was  movahle,  but 
could  not  be  extracted,  and  which  had  existed  six  years. 

Dr.  Duka,  failing  to  extract  the  tumour  by  laying  open  the 
nostril,  resorted  to  the  somewhat  unusual  proceeding  of  cut- 
ting a  wedge  out  of  the  hard  palate,  and  thus,  after  an 
operation  of  three-quarters  of  an  hour,  without  chloroform, 
succeeded  in  removing  the  growth.  The  patient  recovered. 
The  tumour  is  preserved  in  St.  George's  Hospital  Museum, 
and  is  figured  in  the  Pathological  Transactions,  from  which 
the  accompanying  illustration  (fig.  137)  is    by  permission 

Fig.  137. 


taken.  It  has  an  oblong  shape,  and  is  not  unlike  a  middle- 
sized  potato,  with  depressions  and  elevations  passing  irregu- 
larly over  it.     The  upper  part,  which  is  believed  to  have 


OSTEOMA  OF  THE  UPPER  JAW.  285 

been  iu  contact  with  the  cribriform  plate  of  the  ethmoid 
bone,  exhibits  corresponding  delicate  depressions,  with  other 
deeper  sulci  in  fronts  behind,  and  on  the  sides,  probably  for 
the  passage  of  blood-vessels.  At  the  lower  surface  is  a  large 
nipple-like  process,  smooth  throughout,  This  lay  in  contact 
with  the  palatine  process,  and  it  has  the  same  dark  appear- 
ance as  the  anterior  part  of  the  body  which  presented  at  the 
nostril.  At  the  base  of  this  process  is  a  large  hole  piercing 
it  quite  through,  and  allowing  the  tip  of  the  little  finger  to 
enter  it.  In  this  lacuna  was  a  polypoid  mass  which  con- 
tained a  nucleus  of  cartilage,  round  and  flat  like  a  small- 
sized  lentil.  It  was  this  nipple-like  prominence  impinging 
upon  the  nasal  process  which  prevented  the  removal  of  the 
tumour,  without  interfering  with  the  superior  maxillary  bone. 
The  whole  bony  mass,  which  is  of  a  compact  ivory-like 
character,  weighs  1,060  grains :  its  long  diameter  is  nearly 
three  inches^  the  short  one  an  inch  and  two  lines,  and  the 
longest  ch'cumference  seven  inches.  The  microscope  gives 
evidence  of  structure  closely  resembling  that  of  M.  Michon's 
tumour.  There  are  no  distinct  Haversian  systems,  but 
abundance  of  lacunas  arranged  around  vascular  canals.  In 
some  parts  of  the  tumour  the  characters  are  very  much  those 
of  simple  ossified  cartilage,  clusters  of  large  ossified  cells 
being  packed  closely  together. 

This  case  is  remarkable  from  the  fact  that  the  attachment 
of  the  tumour  had  given  way,  and  that  it  was  therefore  loose 
in  the  antrum.  It  would  have  appeared  to  be  unique  in  this 
particular,  but  for  the  publication  in  the  Gazette  M6clicalc 
de  Paris  (April  20,  1867),  of  a  very  similar  case  of  non- 
adherent exostosis,  or  osteoid  tumour,  by  M.  Demarquay,  of 
which  the  following  are  the  leading  features  : — 

A  gentleman,  aged  fifty-three,  in  good  health,  but  the 
subject  of  syphilis,  had  a  swelling  of  the  left  side  of  the 
face,  which  had  existed  for  twenty  years.  It  gave  no  in- 
convenience except  the  disfigurement,  until  six  months 
before  he  applied  to  M.  Demarquay,  when  an  abscess  formed 
and  burst,  leaving  a  fistula.  After  this  neuralgia  came  on, 
and  other  abscesses  formed,  rendering  the  face  swollen  and 


286      NON-MALIGNANT   TUMOURS   OF   UPPER   JAW. 

red.  On  examination  several  fistulse  were  found  both  within 
and  without  the  mouth.  There  was  evidently  suppuration 
within  the  antrum,  probably  due  to  a  sequestrum. 

At  the  operation,  on  Jan.  4, 1867,  it  was  found  impossible 
to  extract  the  sequestrum,  and  M.  Demarquay  therefore 
removed  the  entire  maxilla,  and  the  patient  recovered. 

The  jaw  showed  an  increase  of  size  and  density;  the  front 
wall  of  the  sinus  was  thrown  forward,  so  as  to  present  the 
segment  of  a  sphere,  and  was  thickened  so  that  its  resist- 
ance was  increased.  The  posterior  part  was  also  enlarged, 
and  had  projections  upon  it,  one  of  which  also  pushed  up 
the  floor  of  the  orbit.  There  were  numerous  sinuses  in 
various  parts,  through  which  pus  escaped. 

On  section,  a  white  osteo-cartilaginous  substance  was  found 
filHng  up  the  whole  cavity  of  the  antrum,  but  not  attached 
to  its  walls.  In  some  parts  this  was  of  a  more  fibrous 
character,  whilst  in  others  it  was  dense  bone.  In  the  centre 
was  a  large  fragment  of  bone,  of  a  blackish  colour,  and 
closely  resembling  a  sequestrum.  This  was  surrounded  by 
some  smaller  portions,  and  by  a  cavity  containing  a  quan- 
tity of  pus,  into  which  the  sinuses  could  be  traced.  It  was 
impossible  to  tell  from  which  part  of  the  wall  the  tumour 
had  sprung. 

Here  it  will  be  observed  that  we  have  apparently  an 
earlier  stage  of  a  growth,  which  if  it  had  continued  to  in- 
crease, would  no  doubt  have  developed  into  a  dense  osseous 
tumour,  since  it  consisted  in  great  part  of  cartilage  in  which 
ossification  had  already  partially  occurred.  Dr.  Duka's 
specimen  also  had  some  cartilage  mixed  with  it,  and  its 
microscopic  appearances  showed  evidence  of  ossification  of 
cartilage.  The  post-mortem  specimen  of  ossified  enchon- 
droma  within  the  antrum  in  my  possession,  and  already 
referred  to  (p.  277),  shows  how  slight  the  attachment  of  the 
growth  to  the  wall  of  the  antrum  in  these  cases  is. 

I  think,  therefore,  it  may  be  concluded  that  this  class  of 
bony  tumours  depends  upon  a  form  of  ossification  occurring 
in  cartilage  or  enchondroma. 


287 


CHAPTER  XIX. 

SARCOMATOUS    TUMOUR    OF    THE    UPPER   JAW, 

Spindle-celled  Sarcoma,  Myeloid  Sarcoma,  Ghondro- Sarcoma, 
Ossifying  Sarcoma. 

Under  the  term  Sarcoma^  modern  pathologists  include  all 
tumours  composed  of  tissue,  which  is  either  purely  embryonic, 
or  is  undergoing  one  of  the  primary  modifications  seen  in 
the  development  of  adult  connective  tissue  (Erichsen). 

In  connection  with  the  jaws  various  forms  of  sarcoma  are 
found,  many  of  which  have  hitherto  been  known  by  other 
names,  and  many  recurrent  growths  formerly  called  cancers 
come  properly  into  tliis  class. 

The  Spindle-celled  Sarcoma  is  of  frequent  occurrence 
in  the  upper  jaw,  forming  many  of  the  specimens  formerly 
indiscriminately  named  "  osteo-sarcoma."  It  is  usually  of  a 
yellower  colour  than  the  fibrous  tumour  and  of  softer 
consistence^  and  on  section  it  exudes  a  serous  fluid.  The 
spindle-shaped  cells  are  often  of  great  length  and  size,  and 
each  cell  contains  one  or  more  oval  nuclei,  the  intercellular 
substance  being  homogeneous. 

Under  the  name  of  "  albuminous  sarcoma,"  Mr.  Listen 
has  described  a  case  which  appears  to  be  of  this  kind,  in  the 
Lancet,  Nov.  26,  1836,  which  proved  fatal  after  removal  of 
the  tumour.  The  patient  was  twenty- four  years  of  age, 
and  the  disease  appeared  to  have  originated  in  a  blow,  and 
grew  with  tolerable  rapidity.  The  tumour,  which  is  pre- 
served in  the  College  of  Surgeons'  Museum  (2202),  is  oval 
in  form,  its  chief  diameters  being  about  three  inches  by  two 
inches,   and  contained   spaces  in  which   was  a  glairy  fluid. 


288  SARCOMA   OF   THE    UPPER  JAW. 

coagulable  by  heat.  Mr.  Lane  successfully  removed,  in  1861, 
hoth  upper  jaws,  together  with  the  vomer,  &c.,  which  were 
involved  in  an  "  albuminous  sarcoma,^'  from  a  man  aged 
forty-eight,  whose  case  will  be  found  in  the  Lancet,  Jan. 
25,  1862.  The  tumour  inplicated  both  superior  maxillary 
bones  and  filled  both  nostrils.  It  formed  an  extensive 
convex  irregular  swelling  in  the  mouth,  which  pressed  down 
the  tongue.  Very  little  bony  material  could  be  distinguished 
in  the  position  of  the  palatine  processes  of  the  maxillary  or 
I)alate  bones,  and  the  growth  which  occupied  their  place  was 
soft  and  elastic,  and  was  ulcerated  in  two  or  three  spots  of 
the  size  of  a  fourpeniiy-piece.  The  growth  first  showed 
itself  within  the  left  nostril  three  or  four  years  previously, 
presenting  the  appearance  of  a  nasal  polypus,  and  was 
removed  three  times. 

In  the  same  number  of  the  Lancet  is  the  report  of  a  case 
of  tumour,  also  removed  by  Mr.  Lane,  from  a  child  of  nine 
years,  which  presented  much  the  same  characters.  The 
report  states  that  portions  of  the  growth,  placed  under  the 
microscope,  x^resented  the  characters  of  a  fibro-nucleated 
structure,  being  composed  of  minute  fibres,  in  which  were 
disseminated  numerous  small  oval  nuclei  about  the  size  of 
blood  globules,  measuring  from  the  four-thousandth  to  the 
three-thousandth  part  of  an  inch  in  diameter. 

In  the  Lancet  for  August  31,  1861,  is  the  report  of  a 
remarkable  case  of  fibro-cellular  tumour  of  the  jaw,  under 
the  care  of  Sir  William  Fergusson,  in  which  the  patient  was 
the  subject  of  two  tumours,  one  situated  in  the  right  cheek, 
the  other  in  the  antrum  and  roof  of  the  mouth.  The 
growths  were,  however,  perfectly  distinct  from  one  another, 
and  both  were  removed  at  a  single  operation,  which  was 
attended  with  the  best  results.  Sir  William  Fergusson  had 
seen  the  patient  twelve  months  Ijcfore,  and  the  disease  then 
presented  so  malignant  an  aspect  tliat  he  dissuaded  her  from 
undergoing  any  operation.  Some  montlis  later,  the  disease 
in  the  mouth  was  found  to  ha  an  ulcerated,  sloughy-looking 
mass,  and  the  finger  could  be  readily  passed  alongside  of  it 
into  the  antrum.     Perceiving  tliat  its  progress  had  been  slow, 


SPINDLE- CELLED    SARCOMA.  289 

and  that  it  was  within  tlie  reach  of  surgical  aid,  he  thought 
he  would  give  her  a  chance  of  relief,  more  especially  as  there 
was  no  development  of  disease  in  any  other  situation,  and 
the  tumour  in  the  cheek  was  quite  distinct  from  that  in 
the  jaw. 

The  report  states  that  the  softer  part  of  the  disease 
appeared,  on  microscopical  examination,  to  consist  mainly  of 
a  fibro-granular  matrix,  containing  numerous  corpuscles, 
round,  regular,  of  uniform  size,  granular,  and  with  no  appear- 
ance of  nuclei.  The  much  firmer  tumour  of  the  cheek 
contained  corpuscles  of  a  similar  character,  with  a  large 
proportion  of  the  fibrous  element. 

The  tendency  to  ulceration  which  was  exhibited  in  this 
case  is  a  marked  feature  of  this  form  of  disease,  and  not 
unfrequently  leads  to  difficulty  in  solving  the  question  of 
malignancy.  It  is  seldom  that  in  the  case  of  the  upper  jaw 
the  skin  becomes  involved  in  the  disease,  but  in  the  lower 
jaw  this  frequently  happens,  and  large  fungous  protrusions 
occur  which  may  be  mistaken  for  open  cancer.  The  history 
of  the  case,  together  with  the  absence  of  any  enlargement 
of  the  lymphatic  glands,  is  sufficient  to  mark  the  nature  of 
the  growth. 

In  his  paper  on  Osteo-sarcoma,  in  the  fourth  volume  of 
the  DuUin  Hospital  Reports,  Sir  Philip  Crampton  says  that 
"  in  the  earlier  stages  of  the  disease  the  tumour  consists  of 
a  dense  elastic  substance  resembling  fibro-cartilaginous  struc- 
ture, but  the  resemblance  is  more  in  colour  than  consistency, 
for  it  is  not  nearly  so  hard,  and  is  granular  rather  than 
fibrous,  so  that  it  'hreahs  slwrt.'  On  cutting  into  the  tumour 
the  edge  of  the  knife  grates  against  spicula,  or  small  grains 
of  earthy  matter  with  which  its  substance  is  beset."  The 
tumours  described  above  correspond  very  closely  to  this 
definition,  especially  that  of  Mr,  Liston,  which  is  said  to  be 
"  chiefly  composed  of  a  firm  substance  like  fibro-cartilage, 
with  spicula  of  bone." 

In  his  work  on  the  "  Diseases  of  the  Bones"  (p.  283), 
Mr.  Stanley  mentions  "  fatty"  tumours  of  the  superior 
maxilla.      He  refers  (p.  104)  to  a  specimen  in  St.  Bartho- 

U 


290  SARCOMA    OF    THE    UPPER   JAW. 

lomew's  Hospital  Museum  (I.  151),  of  which  the  following 
is  the  description  : — 

"  Sections  of  a  tumour  which  occupied  the  situation  of  the 
superior  maxillary  bone,  and  was  removed  by  operation. 
The  whole  of  the  natural  structure  of  the  superior  maxillary 
bone  has  disappeared.  The  mucous  membrane  which  covered 
the  palatine  surface  of  the  bone  extends  over  a  part  of  the 
tumour.  The  morbid  growth  consists  of  a  moderately  firm 
fatty-looking  substance,  with  minute  cells  and  spicula  of  bone 
dispersed  through  it. 

"  From  a  man,  aged  forty-six.  The  disease  returned  after 
the  operation,  and  the  patient  died  in  consequence  of  hemor- 
rhage from  ulceration  of  the  internal  carotid  artery,  which 
became  involved  in  an  extension  of  the  disease." 

This,  as  far  as  can  be  judged,  would  ajDpear  to  have  been 
an  example  of  spindle-celled  sarcoma  or  osteo-sarcoma,  which 
had  undergone  fatty  degeneration  ;  and  the  same  may,  I 
imagine,  be  said  of  the  cases  referred "  to  by  Von  Siebold  as 
osteo-steatomata.  The  disease  would  appear  to  be  a  rare 
one,  as  it  is  not  mentioned  by  most  authors. 

The  modern  spindle-celled  sarcoma  includes  both  the  cases 
formerly  classed  as  recurrent  fibroid  tumours,  and  those  which 
have  been  termed  fibro-sarcomata,  from  containing  numerous 
young  cells,  round  or  oat-shaped,  between  the  fibres. 

It  is  an  undoubted  fact  that  fibrous  tumours  do  recur  in 
the  upper  jaw  after  complete  removal ;  of  this  Mr.  Listen's 
series  of  specimens,  already  referred  to,  gives  more  than  one 
example,  and  it  is  probable  that  careful  microscopic  exami- 
nation would  prove  that  some  of  them  exhibit  the  peculiar 
"  oat-shaped  nucleated  cells,"  described  by  Sir  J.  Paget  as 
characteristic  of  the  recurrent  tumour.  It  is  not  surprising 
that  these  tumours  should  liave  been  considered  as  examples 
of  the  ordinary  fibrous  tumour,  since  Sir  J.  Paget  himself 
observes,  in  speaking  of  a  well-marked  specimen,  "without 
the  nucroscope,  I  should  certainly  have  called  it  a  fibrous 
tumour." 

In  connection  with  this  subject  I  may  quote  the  following 
extract  from  the  report  upon  diseases  of  the  jaw,  in  the 


SPINDLE-CELLED    SARCOMA.  291 

Medical  Times  and  Gazette,  Sept.  3,  1859 : — "  The  only 
example  which  we  have  to  quote  of  recurrent  fibroid  tumour 
developed  in  connection  with  the  jaws,  is  one  in  which  the 
diagnosis  of  that  variety  of  tumour  and  true  cancer  is  by  no 
means  positive.  It  is  that  of  a  woman,  aged  thirty-four, 
under  Mr.  Cock's  care,  in  Guy's  Hospital,  at  different  times, 
for  two  or  three  years  (1854  and  1856).  The  growth 
occupied  the  right  antrum,  and  extended  into  the  nose  ;  on 
several  occasions  Mr.  Cock  dissected  up  the  cheek  in  front, 
laid  bare  the  cavity,  and  gouged  out  the  tumour  and  the 
bone  to  which  it  was  attached.  The  parts  always  healed 
quickly,  but  the  disease  soon  returned.  The  tumour  had 
the  microscope  features  of  a  recurrent  fibroid,  as  distinct 
from  those  of  a  true  cancer,  and  the  fact  that  it  continued 
to  recm?  in  the  same  place,  but  did  not  cause  disease  of  the 
glands,  is  confirmatory  of  that  diagnosis.  The  woman  was 
very  pallid  and  cachectic,  but  her  cachexia  did  not  exactly 
resemble  that  of  cancer.  We  lost  sight  of  her  towards  the 
end  of  1856,  and  do  not  know  the  final  result  of  her  case. 
Probably  she  has  since  died  of  her  disease.^' 

In  March,  1867,  I  had  the  opportunity  of  seeing  a  patient 
of  Mr.  Lawson's,  a  lady  aged  thirty-three,  from  whom,  in 
the  preceding  May,  that  gentleman  had  removed  a  recurrent 
fibroid  tumour  of  the  left  orbit.  From  this  operation  she 
perfectly  recovered,  but,  four  months  before  I  saw  her,  the 
patient  had  found  a  small  hard  swelling  of  the  left  side  of 
the  hard  palate.  This  rapidly  increased,  spreading  back- 
wards into  the  soft  palate,  and  forwards  so  as  to  press  upon 
the  incisor  teeth.  The  swelling  was  irregular  in  outline,  but 
with  a  perfectly  smooth  surface,  and  was  so  soft  and  elastic 
that  it  conveyed  the  impression  of  fluid,  and  had  been  punc- 
tured. Mr.  Lawson  removed  the  whole  of  the  left  side  of 
the  hard  palate  and  as  much  of  the  soft  palate  as  w^as  in- 
volved in  the  disease,  and  the  patient  made  a  perfect  recovery. 
Tour  months  afterwards  the  patient  again  appeared,  the 
disease  having  recurred  on  the  right  side  of  the  hard  palate. 
There  was  also  a  fibroid  tumour  in  the  parotid  region,  which 
had  been  present  some  years,  and  had  now  begun  to  increase 

u2 


292  SARCOMA  or  the  upper  jaw. 

in  size.  Mr.  Lawson  removed  the  tumour  of  the  palate  with 
the  gouge,  including  all  the  periosteum  involved  by  the 
growth,  and  excised  the  parotid  tumour.  The  patient  re- 
covered, and  has  had  no  further  return  up  to  the  present 
time.  Tlie  growths  gave  inimistakable  microscopic  evidence 
of  their  recurrent  fibroid  nature. 

Myeloid  Sarcoma  is  found  in  the  upper  as  well  as  in  the 
lower  jaw,  in  which  latter  position  the  specimen  first  de- 
scribed by  Sir  J.  Paget  arose.  The  occurrence  of  myeloid 
cells  in  specimens  of  epulis  has  been  already  referred  to. 
and  it  might  naturally  be  expected  therefore  that  the  same 
characters  might  be  discovered  in  tumours  of  the  jaw.  In 
fact,  Dr.  Eugene  Xelaton,  in  a  valuable  treatise,  published  in 
1860,  "  Des  Tumeurs  a  Myeloplaxes,"  says  "  la  siege 
d'election  des  tumeurs  a  myeloplaxes  est,  sans  contredit, 
dans  les  os  maxillaires,  particulierement  an  niveau  de  leur 
bord  alveolaire,"  and  supports  his  statement  by  quoting 
twenty-nine  cases  of  tlie  disease  in  this  situation. 

The  diagnosis  of  myeloid  tumours  of  the  jaw  is  by  no 
means  easy,  since  the  bone  is  slowly  expanded,  much  as  it 
would  be  by  a  cyst,  or  by  any  benign  tumour.  If  the 
disease  originate  on  the  exterior  of  the  bone,  or  when 
springing  from  the  interior,  if  sufficient  absorption  of  the 
bone  have  taken  place  to  allow  the  tumour  to  appear 
beneath  the  mucous  membrane,  the  characteristic  dark 
maroon  colour  of  the  tumour  may  be  perceived.  Cysts 
occasionally  form  in  the  substance  of  a  myeloid  tumour, 
and  an  exploratory  puncture  of  these  may  yield  fluid  in 
which  the  characteristic  myeloid  cells  may  be  discovered 
microscopically. 

Myeloid  disease  occurs  mostly  before  the  age  of  twenty- 
five.  Sir  J.  Paget  ("Surgical  Pathology,"  p.  524)  quotes 
two  cases  of  Sir  William  Lawrence's,  occuri'ing  in  the  upper 
jaws  of  women  of  twenty-one  and  twenty-two  years  of  age, 
the  latter  of  which  illustrates  extremely  well  the  recurrence  of 
myeloid  growths  (of  which  there  can  be  no  question),  and 
also  the  very  curious  fact  tliat  a  tumour  on  the  opposite 
side    to    that    removed,  and  wliicli  presented    appearances 


MYELOID    SARCOMA. 


293 


exactly  corresponding  to  it,  spontaneously  subsided.  The 
specimen  is  in  St.  Bartholomew's  Hospital  Museum  (1.4-59). 
Fig.  138  shows  a  patient  from  whom  Mr.  Canton  removed 
a  myeloid  tumour  in  1864.  She  was  thirty-five  years  old, 
and  the  tumour  appeared  to  have  followed  a  blow.  It  had 
been  twice  removed  before  she  came  under  Mr.  Canton's 
care,  and    that    gentleman  successfully  removed    the    left 

Fig.  138. 


superior  maxilla  with  the  tumour,  a  portion  of  which  hung 
down  into  the  pharynx.  The  tumour  was  brought  before 
tlie  Pathological  Society  of  London,  in  December,  1865,  and 
the  following  is  a  description  of  the  tumour,  by  Messrs. 
Bryant  and  Adams,  to  whom  the  specimen  was  referred  : — ■ 
"  Tlie  parts  placed  in  our  hands  for  examination  consisted  of 


294  SARCOMA    OF   THE    UPPER   JAW, 

the  left  superior  maxillary  Lone,  including  its  orbital  plate, 
from  the  inferior  surface  of  which  appeared  to  gi'ow  a  large 
tumour,  which  filled  the  cavity  of  the  antrum,  and  projected 
forwards  and  inwards  into  the  nasal  cavity.  Tliere  was  also 
a  second  and  loose  portion,  the  size  of  a  walnut,  which 
appeared  to  have  been  broken  off  during  the  operation,  and 
was  said  to  have  projected  posteriorly  towards  the  pharynx. 
The  external  wall  of  the  antrum  was  not  expanded  so  fully 
as  is  usually  found  in  tumours  of  the  antrum.  The  timiour,. 
which  had  been  some  time  in  spirit,  was  of  a  firm  fibrous 
nature,  and  irregularly  lobulated,  and  it  had  a  dense  capsule. 
On  section,  the  structure  presented  a  large  amount  of 
fibrous  tissue,  arranged  in  a  curvilinear  form,  intermixed 
M'ith  other  tissue  not  easily  broken  up.  Microscopically 
examined,  the  tumour  consisted  of  an  abundance  of  fibrous- 
tissue,  which  formed  the  stroma,  containing  in  its  meshes 
innumerable  cells,  generally  of  a  circular  or  ovoid  form,, 
varying  from  two  to  three  diameters '  of  a  blood-corpuscle, 
and  some  of  a  still  larger  size.  The  cells  were  all  nucleated,^ 
usually  containing  several  nuclei,  and  frequently  presenting 
a  granular  appearance.  Large  compound  cells  were  abun- 
dant in  the  posterior  and  softer  lobe  of  the  tumour,  and  a 
few  elongated  cells  were  seen  amongst  the  fibrous  tissue. 
These  large  compound  cells  presented  very  much  the  ap- 
pearance of  the  polynucleated  cells  met  with  in  myeloid 
tumours." —  Transactions  of  the  Pathological  Society,  vol.  xvii. 
Tlie  subsequent  history  of  this  patient  is  given  as  follows, 
in  the  Lancet  of  January  26,  1872,  and  it  is  remarkable 
that  the  tumour  on  one  side  should  have  had  a  character 
differing  from  that  on  the  other  : — "  In  June,  1871,  she  again 
presented  herself  at  the  Charing  Cross  Hospital  with  a  large 
tumour  filling  up  the  antrum  of  the  right  upper  maxilla, 
and  extending  forwards,  causing  a  projection  of  the  upper 
lip.  Mr.  Canton  accordingly  removed  the  remaining  upper 
maxilla.  The  operation  was  perfectly  successful,  and  pre- 
sented in  itself  no  points  of  particular  interest.  The  edges 
of  the  incision  were  brought  together  with  silver  sutures, 
and  no  dressing  of  any  kind   was  used,  the  mouth  being. 


MYELOID    SARCOMA.  295 

simply  kept  perfectly  clean  and  sweet  by  the  frequent  use 
of  Condy's  fluid.  Within  a  week  of  the  operation  she  left 
her  bed,  and  within  three  weeks  she  was  discharged  from 
the  hospital.  Five  months  later  the  patient  wrote  to  say 
that  she  had  enjoyed  perfect  health  since  she  had  left  the 
hospital.  On  microscopic  examination  the  tumour  proved 
to  be  simply  fibrous.  It  had  been  growing  for  a  year 
before  removal.  Notwithstanding  that  a  great  part  of  the 
framework  of  the  face  had  been  taken  away,  and  that  a 
portion  of  the  orbital  plate  was  removed,  at  both  operations, 
there  was  remarkably  little  deformity  of  the  face.  The 
patient  had  lost  all  power  of  muscular  expression,  but 
beyond  this  there  was  nothing  to  attract  attention,  except  a 
slight  falling  in  of  the  upper  lip  on  the  right  side.  There  was 
no  falling  in  of  the  nose,  the  raphe  of  what  was  the  roof 
of  the  mouth  deriving  great  support  from  a  firm  pseudo- 
palate,  which  had  formed  of  cicatricial  tissue  after  the  first 
operation.  The  cicatrices  of  the  incisions  were  scarcely 
noticeable,  as  they  followed  the  natural  lines  of  the  face." 

Mr,  Canton  has  obliged  me  with  the  portrait  and  history 
of  a  case  of  still  more  marked  myeloid  disease  of  the  upper 
jaw,  which  was  also  under  his  care.  The  patient  was  forty- 
six  years  of  age,  which  is  decidedly  advanced  for  the  disease, 
and  the  tumour  grew  with  unusual  rapidity.  Mr.  Canton 
removed  the  jaw  in  Dec.  1866,  and  I  had  the  opportunity  of 
seeing  the  patient  in  Jan.  1867,  when  he  was  quite  well,  but 
had  still  a  small  fistulous  opening  on  the  face.  Dr.  Tonge 
carefully  examined  the  tumour  (which  is  preserved  in  the 
Museum  of  Charing  Cross  Hospital),  and  has  kindly  fur- 
nished me  with  the  following  report  upon  it  and  upon  the 
microscopic  appearances  it  presented  : — "  The  tumour  was 
about  the  size  and  shape  of  a  large  hen's  egg  that  had  been 
flattened  slightly  in  the  transverse  direction,  and  measured 
(after  being  in  moderately  strong  spirit  for  some  days)  about 
two  and  three-quarter  inches  in  length,  from  one  and  three- 
quarters  to  two  inches  transversely,  and  about  one  and  a 
half  inch  in  thickness.  It  was  of  firm  consistence  through- 
out, and  on  section  presented  a  wdiitish  appearance,  with 


296  SARCOMA    OF   THE    UPPER    JAW. 

a  small  pink  patch  or  two,  and  a  whitish,  creamy-looking 
juice  could  be  scraped  from  the  cut  surface.  Tlie  micro- 
scopical appearances  of  a  portion  of  a  thin  section  of  the 
tumour,  that  had  been  preserved  in  glycerine  and  coloured 
with  carmine,  are  represented  in  the  accompanying  drawing, 
whicli  was  taken  with  the  aid  of  tlie  camera  kicida.  The 
fibrous  element  was  much  less  abundant  than  the  cellular, 
and  consisted  of  white  fibrous  tissue,  with  numerous  fine 
curling  fibres  of  yellow  elastic  tissue,  and  many  small  oval 
and  rounded  nuclei  were  imbedded  in  the  fibrous  structure. 
The  greater  portion  of  the  tumour  seemed  to  be  composed 
of  cells.  These  were  mostly  of  an  irregularly-rounded  form, 
often  with  pointed  processes,  and  some  shuttle-shaped  and 
spindle-shaped,  of  a  somewhat  trapezoidal  form,  were  not 
uncommon,  while  a  few  cells  presented  the  character  of 
those  distinctive  of  myeloid  tumours.  All  the  cells  con- 
tained one,  and  often  two,  very  large  and  generally  oval 
nuclei,  with  one,  two,  or  three  nucleoli,  and  a  variable  num- 
ber of  oil  globules.  The  myeloid  cells  observed  were  of 
irregular  outline,  and  contained  from  three  to  five  nuclei, 
with  single  or  double  nucleoli — one  very  large  cell  con- 
tained six  nuclei. 

"  These  cells  were  not  very  numerous,  but  appeared  suffi- 
ciently so  to  justify  the  application  of  '  myeloid'  to  the  tumour, 
though,  to  the  naked  eye,  and  on  a  superficial  microscopical 
examination,  it  presented  many  of  the  appearances  of  cancer." 

In  the  Museum  of  the  College  of  Surgeons  are  two  speci- 
mens (2245  and  A),  the  two  superior  maxilhe  of  a  woman, 
aged  twenty-one,  which  were  given  me  by  Messrs.  Andrews 
and  Coates,  of  Salisbury,  who  removed  them.  Tlie  left  upper 
jaw  has  been  macerated,  showing  a  calcified  tumour  springing 
from  the  anterior  part ;  the  right  jaw  has  a  growth  involv- 
ing the  anterior  portion  extending  into  the  nasal  fossa. 
The  growth  in  these  cases  was  regarded  by  the  operators  as 
an  example  of  scirrhus,  but  I  am  enabled  by  the  kindness  of 
Dr.  Lush,  of  Weymouth,  to  correct  this  statement,  by  a  record 
which  he  has  of  the  microscopic  details  observed  when  the 
tumours  were  receut,  as  follows  : — 


VASCULAR    SARCOMA.  297 

"  A  section  showed  numerous  splieroidal  cells  with  one, 
two,  or  more  nuclei,  free  matter  and  some  compound  cells." 
The  tumour  should  therefore  doubtless  properly  be  regarded 
as  myeloid.  The  history  of  the  patient  is  the  following : — • 
Jane  F.,  aged  twenty-one,  was  admitted  into  the  Salisbury 
Infirmary,  July  24, 1858,  for  a  tumour  of  the  left  upper  jaw. 
The  operation  of  removal  of  the  left  upper  jaw  was  performed 
by  Mr.  Andrews,  and  she  was  made  an  out-patient  Aug.  28, 
1858.  She  was  readmitted  on  Oct.  1,  1859^  under  Mr. 
Coates,  having  a  fortnight  before  perceived  a  small  growth 
occupying  the  edge  of  the  alveolar  process  at  the  site  of  the 
left  upper  incisor,  which  became  rapidly  exquisitely  painful, 
and  involved  the  alveolus  of  the  right  side,  and  also  the 
upper  lip.  Mr.  Coates  removed  the  remaining  right  superior 
maxilla  under  chloroform,  Oct.  13,  1859.  The  portion  of  the 
lip  covering  the  small  tumour  (which  was  about  the  size  of 
a  hazel-nut)  was  also  removed,  and  found  to  be  infiltrated 
with  disease.  The  patient  was  discharged  cured  Nov.  5,  1859, 
and  was  in  perfect  health  in  1866. 

Vascular  tumours  of  a  non-malignant  character,  but 
closely  resembling  erectile  tumours  in  other  parts  of  the 
body,  have  been  occasionally  met  with  in  the  upper  jaw, 
though  the  majority  of  the  pulsating  tumours  of  bone  are 
examples  of  vascular  sarcoma.  Mr.  Liston,  in  1841,  success- 
fully removed  a  specimen  of  the  kind,  which  is  preserved  in 
University  College,  from  a  young  man  aged  twenty-one. 
The  tumour  was  of  more  than  three  years'  growth,  and  pro- 
jected into  the  nares  and  pharynx,  forming  a  tumour  beneath 
the  cheek ;  but  the  preparation  shows  that  the  alveolus  and 
all  the  lower  and  anterior  part  of  the  maxilla  were  not 
involved  in  the  disease.  The  tumour  was  not  painful,  but 
frequent  hiemorrhages  had  taken  place  from  its  surface.  The 
case  will  be  found  in  the  Lancet,  Oct.  9,  1841.  Mr.  Liston 
removed  the  jaw,  cutting  completely  beyond  the  disease,  and 
remarks  concerning  it  {Lancet,  Oct.  26,  1844)  : — "  It  was  a 
curious-lookiniT  tumour,  and  it  struck  me  that  it  was  of  a 
fibrous  character,  not  growing  from  the  jaw,  but  involving 
it.      Mr.  Marshall  some  months  afterM'ards   discovered  that 


298  SARCOMA    OF   THE    UPPER   JAW. 

the  whole  mass  was  erectile You  will  see  that  it 

is    as    complete    and   beautiful   a  specimen   of  an    erectile 
tumour  as  any  that  I  have  yet  shown  you." 

The  tumour,  which  is  in  the  Museum  of  University  College 
(684),  is  described  as  follows  in  the  catalogue  by  Mr.  Marcus 
Beck: — "A  large  tumour  of  the  pterygo-maxillary  fossa  re- 
moved with  the  upper  jaw.  The  specimen  includes  the  whole 
of  the  maxilla  except  a  narrow  strip  of  its  palatine  process, 
and  small  portions  of  the  nasal  and  malar  processes,  the 
whole  of  the  lower  part  of  the  palate  bone,  and  the  lower 
portions  of  both  pterygoid  plates  of  the  sphenoid,  and  the 
inferior  turbinated  bone. 

"  The  tumour,  which  measures  about  three  inches  in  the 
antero-posterior  direction,  has  grown  from  the  posterior 
surface  of  the  maxilla,  and  filled  the  sj)heno-maxillary  and 
lower  part  of  the  temporal  fossse,  and  has  passed  far  back- 
wards under  cover  of  the  ramus  of  the  inferior  maxilla  so  as, 
on  the  inner  side,  to  have  projected  -within  the  pharynx ; 
and  from  the  anterior  part  of  the  tumour  a  portion  has 
grown  forwards  beneath  tlie  hard  palate  into  the  mouth. 
The  posterior  half  of  the  tumour  is  deeply  cleft  into  lobes. 
On  the  inner  aspect  of  the  parts  a  piece  of  the  tumour  has 
been  cut  away ;  the  divided  surface  has  a  uniformly  open, 
cavernous  structure,  like  that  of  the  corpus  spongiosum 
penis,  the  meshes  of  which  are  nowhere  occupied  by  a  solid 
substance,  and  probably  allowed  of  the  circulation  of  blood 
through  them.  Tlie  tumour  is  everywhere  bounded  by  a 
dense  layer  of  fibrous  tissue.  The  cavity  of  the  antrum  is 
entirely  unaffected." 

M.  G  ensoul  also  met  with  an  erectile  tumour  springing 
from  the  antrum,  in  one  of  the  cases  from  which  he  success- 
fully extirpated  the  upper  jaw. 

Mr.  Butcher,  of  Dublin,  has  described  ("  Operative  and 
Conservative  Surgery/'  p.  249)  a  case  of  successful  removal 
of  the  right  upper  jaw,  on  account  of  a  large  fibro-vascular 
tumour  springing  from  the  antrum  of  a  lad  of  sixteen.  Nine 
months  before  admission  he  had  had  a  polypoid  growth  re- 
moved from  tlie  nostril,  oiving  rise  to  severe  hiemorrhage.    It 


VASCULAR   SARCOMA.  299 

reappeared  in  a  month,  and  increased,  so  that  when  he  came 
under  Mr.  Butcher's  care  there  was  considerable  deformity 
of  the  face,  and  the  nostril  was  filled  with  the  tumour,  whicli 
projected  behind  the  soft  palate.  After  the  boy  had  been 
in  hospital  a  few  days  the  tumour  suddenly  increased  with 
great  rapidity,  and  interfered  so  much  with  respiration  and 
deglutition  that  Mr.  Butcher  at  once  removed  tlie  jaw,  and 
the  patient  made  a  good  recovery. 

The  following  is  the  description  given  of  the  tumour : — 
"  The  structure  of  the  tumour  presented  many  interesting 
peculiarities.  Its  attachment  and  origin  sprang  from  the 
outer  part  of  the  antrum.  Not  only  was  it  incorporated 
with  the  lining  membrane,  but  it  likewise  implicated  the 
osseous  wall.  The  surface  from  which  it  sprang  in  the 
recent  state  was  softened,  vascular,  and  pulpy,  the  upper 
surface  of  the  tumour  was  lobulated  where  it  encroached 
upon  the  orbit,  and  elevated  its  floor ;  the  lobules  were  of 
various  sizes — some  very  small,  but  each  consistent  in  struc- 
ture, and  invested  by  a  dense  capsule  in  a  similar  way  to  the 
larger  masses  of  the  growth.  The  entire  tumour  was  re- 
markable for  its  great  vascularity,  which  was  more  parti- 
cularly confined  to  the  posterior  and  upper  surface ;  while 
on  section  the  structure  was  dense  by  comparison,  pale, 
eminently  firm,  and  partaking  of  a  fibrous  matted  nature. 
This  integral  arrangement  was  very  manifest  under  close 
examination  with  the  microscope,  and  cleared  away  the  sus- 
picion which,  on  superficial  inspection,  might  have  been 
created  of  encephaloid  disease  being  the  synonym  most 
applicable  to  the  growth.  There  was  a  total  absence  of  all 
nucleated  cells,  either  globular,  caudate,  or  spindle-shaped  ; 
and,  above  all,  the  section  of  any  part  only  yielded  a  minute 
quantity  of  serum  or  blood  on  pressure,  and  not  the  true 
succus  of  cancerous  tissue.  The  tumour,  though  destructive 
to  the  neighbouring  parts  by  pressure,  yet  did  not  appro- 
priate or  incorporate  them  in  its  structure.  This  peculiarity 
of  non-malignant  growths  was  strikingly  manifest  in  the 
present  instance ;  for  by  pressure,  producing  interstitial  ab- 
sorption, the  cancellated  structure  of  the  ethmoid  and  infe- 


300  SARCOMA    OF    THE    UPPER   JAW. 

rior  spongy  bones  was  attenuated  and  removed ;  and  by  the 
same  process  the  vomer  was  detached  from  its  position — a 
few  shreds  of  it  being  spared  and  hanging  loosely  on  the 
sinistral  siu'face  of  the  tumour.  The  vascularity  of  the 
growth,  though  remarkable  on  the  surface,  yet  did  not  per- 
meate its  texture ;  hence  a  tendency  to  degenerate  by 
assumed  depravity  of  action  was  lessened.  Again,  the  .vas- 
cularity of  the  surface  will  readily  account  for  the  repeated 
and  profuse  losses  of  blood — a  point  of  great  practical  value, 
because  placing  the  surgeon  on  his  guard  as  to  the  impor- 
tance which  should  be  attached  to  those  repeated  losses,  in 
constituting  a  diagnostic  feature  confirmatory  of  malignant 
disease." 

Chondrosarcoma,  in  which  spindle-  or  round-celled  sarco- 
matous elements  are  mixed  with  the  cartilage  forming  the 
bulk  of  the  tumour  occurs  occasionally  in  the  upper  jaw,  and 
is  apt  to  be  followed  by  secondary  deposits  in  the  lungs, 
this  clinical  fact  distinguishing  it  from  the  ordinary  enchon- 
droma.  In  1879,  I  was  consulted  respecting  a  young  lady 
who,  two  years  l)efore,  had  had  removed  from  the  floor  of 
the  orbit  a  small  growth  wliicli  grew  from  the  orbital  plate 
and  displaced  the  eyeball.  The  growth  recurred,  and  when 
I  saw  the  patient  both  nostrils  were  completely  blocked  ; 
there  was  slight  bulging  of  the  antrum,  and  nobbly  swellings 
of  the  size  of  a  sixpence  on  the  raphe  or  the  hard  palate  on 
the  left  side,  and  another  on  the  right  side  of  the  palate. 
The  frontal  Ijone  also  seemed  affected.  I  advised  against  an 
operation,  but  another  surgeon  removed  the  upper  jaw,  and 
was  unable  to  take  aAvay  the  wliole  of  the  disease,  which 
proved  to  be  chondro-sarcoma. 

OssifTjing  Sarcoma  and  Osteoid  Chondro-sarcoma  imply  the 
occurrence  of  ossification  in  tumours  containing  sarcomatous 
elements,  and  include  the  cases  hitherto  described  as 
"  osteoid  cancer."  A  good  specimen  of  the  kind  is  preserved 
in  the  Museum  of  the  College  of  Surgeons  (1712),  of  which 
the  history  with  an  accompanying  drawing  is  recorded  in  Mr. 
Howship's  "  Surgical  Observations."  The  specimen  has  been 
macerated,  and  the  part  wliich  remains  consists   of   an   oval 


OSSIFYING    SARCOMA.  301 

mass  of  light  cancellous  bone,  about  five  inches  in  its 
chief  diameter,  and  very  slightly  connected  with  the 
remaining  bones  of  the  face.  At  its  lowest  part  it  pre- 
serves somewhat  of  the  form  of  the  alveolar  border  of  the 
upper  jaw,  and  the  incisor,  canine,  and  bicuspid  teeth  are 
implanted  in  it. 

The  patient  was  a  woman,  aged  thirty,  who  died  in  the 
Westminster  Hospital  from  haemorrhage,  consequent  upon 
the  extraction  of  some  teeth  from  the  tumour  in  question, 
which  is  described  as  "  fleshy,"  and  of  a  florid  red  colour 
where  it  appeared  in  the  mouth.  The  tumour  had  been 
growing  five  years.  No  details  are  furnished  by  Mr.  How- 
ship  as  to  the  post-mortem  examination  of  this  patient,  but 
the  skull  shows  a  very  important  feature — a  circular  portion 
of  the  frontal  bone  just  above  the  right  temple,  which  is 
thin  and  perforated  by  several  small  apertures,  apparently  in 
consequence  of  the  growth  of  a  tumour  from  the  dura  mater. 
There  is  thus  evidence  of  a  secondary  growth  within  the 
skull ;  and  taking  the  history  of  the  case  together  with  the 
specimen,  I  am  inclined  to  regard  this  as  an  example  of 
sarcomatous  disease. 

0.  Weber  quotes  fi^om  Titman  (1757)  a  remarkable  case 
which  he  considers  of  the  same  kind.  The  tumour  was  in 
a  youth  of  fourLeen,  and  had  been  growing  for  four  years, 
and  finally  occupied  the  entire  face.  It  had  displaced  the 
eye,  the  nose,  and  the  lower  jaw,  and  projected  in  such  a 
way  into  the  mouth  and  fauces  that  the  patient  died  of 
inanition.  The  mass  weighed  six  pounds,  and  on  being  cut 
through  was  quite  white,  and  very  hard,  and  had  radiating 
masses  of  bone  interspersed  through  its  substance. 


302 


CHAPTEE    XX. 

MALIGNANT    TUMOUES    OF    THE    UPPER    JAW. 

Round-celled  Sarcoma  and  Epithelioma. 

Eound-celled  Sarcoma  or  medullary  sarcoma  is  of  frequent 
occurrence  in  the  upper  jaw,  and  from  its  vascularity  and 
rapidity  of  growth  it  has  often  been  mistaken  for  medullary 
cancer,  which  in  its  clinical  history  it  closely  resembles.  In 
the  majority  of  cases  the  disease  begins  in  the  antrum,  for 
the  protruding  masses,  which  are  found  in  the  nose  or  mouth, 
are  but  secondary  to  a  formation  within  that  cavity.  One  of 
Mr.  Listen's  cases  is  conclusive  on  the  point,  the  preparation 
being  preserved  in  the  College  of  Surgeons  (1059),  with  the 
following  description  : — "  The  greater  part  of  a  left  superior 
maxillary  bone,  with  a  tumour  formed  in  the  antrum,  re- 
moved by  operation.  The  tumour  measures  about  two 
inches  in  its  greatest  diameter,  and  projects  forwards  over 
the  right  canine  and  bicuspid  teeth.  It  is  pale,  soft,  and 
liomoseneous,  and  the  surface  of  its  section  is  like  that  of 
Ijrain.  At  the  upper  part  its  tissue  is  broken,  and  was 
mixed  with  blood  :  in  its  recent  state  it  was  more  brain- 
like. The  patient,  William  Thomson,  was  sixteen  years 
(jld.  The  disease  had  been  observed  for  two  years.  He 
had  often  suffered  pain  in  the  situation  of  the  first  molar 
tooth,  which  had  been  in  a  decayed  state  for  a  considerable 
time  previous  to  his  discovering  any  swelling  of  the  cheek. 
During  the  two  months  preceding  the  operation  the  tumour 
liad  grown  rapidly.  Three  years  and  a  half  after  its  re- 
moval tlie  patient  was  in  good  health." — See  Listen's  papei-. 
Medico- Chirurgical     Transactions,    vol.     xx.     In    this    case, 


ROTJND-CELLED   SARCOMA.  303 

which  was  fortunately  submitted  to  operation  at  a  very  early 
period,  the  disease  was  still  confined  to  the  antrum,  and  the 
removal  of  the  jaw  therefore  included  the  whole  of  it. 
Unfortunately,  in  too  many  cases  the  disease  is  much  more 
advanced  before  it  is  brought  under  the  notice  of  the 
surgeon,  when  therefore  the  possibility  of  complete  extirpa- 
tion is  much  reduced. 

Medullary  sarcoma  of  the  jaw  closely  resembles  the  same 
disease  in  other  parts  of  the  body,  rapidity  of  growth,  with 
softness,  and  a  tendency  to  f  ungate  on  the  part  of  the  tumour 
itself,  being  the  main  characteristics.  The  direction  which 
the  disease  takes,  and  the  effects  therefore  which  it  produces, 
will  vary  in  different  examples.  Frequently  it  forms  a 
considerable  projection  on  the  cheek,  causing  epiphora  from 
closure  of  the  nasal  duct,  and  oedema  of  the  lower  eyelid ; 
and  in  the  later  stages  enlargement  of  the  facial  veins, 
without  the  least  invasion  of  the  hard  palate,  and  with  but 
slight  mterference  with  tlie  nostril.  The  specimen  of 
medullary  sarcoma  represented  in  fig.  139  (College  of  Sur- 

FiG.  139. 


geons'  Museum,  2243),  illustrates  the  point,  a  large  tumour 
being  developed  externally.  The  patient  was  a  man,  aged 
forty-four,  who  came  under  the  care  of  Mr.  Craven,  of  Hull, 
in  1863,  with  a  large  rounded  tuiiiour  of  the  right  cheek,  of 


304         MALIGNANT   TUMOURS    OF   UPPER    JAW. 

the  size  of  an  orange,  extending  from  the  external  process  of 
the  frontal  bone  and  zygoma  above,  to  the  angle  of  the 
mouth  below  (almost  completely  closing  the  right  eye),  and 
from  the  side  of  the  nose  to  the  ramus  of  the  lower  jaw. 
The  colour  of  the  integument  was  natural,  except  at  the 
upper  part  below  the  eye,  where  it  presented  a  rather  livid 
appearance,  and  several  veins,  not  of  large  size.  It  was 
very  firm  to  the  touch,  but  elastic,  especially  at  the  outer 
part.  Pressure  and  handling  caused  little  or  no  pain.  The 
interior  of  the  mouth  on  the  right  side,  from  the  alveolar 
process  (which  was  concealed  by  the  growth  or  embraced  in 
it)  to  the  inside  of  the  distended  cheek,  presented  a  large 
excavated  sore  of  a  greyish  sloughy  aspect  and  foetid  odour. 
This  part  of  the  tumour  was  softer  to  the  touch  than  that 
which  showed  itself  externally.  It  did  not  encroach  on  the 
palate,  which  was  of  the  natural  width.  There  were  no 
enlarged  glands  beneath  the  jaw.  The  patient  seemed  a 
pretty  healthy  man.  The  tumour  had  been  growing  seven- 
teen weeks.  Mr.  Craven  excised  the  tumour,  and  the  patient 
made  a  good  recovery,  but  died  fifteen  months  afterwards 
from  a  recurrence  of  the  disease.  The  tumour  (fig.  139) 
was  rounded  and  lobed,  especially  that  part  which  occupied 
the  pterygo-maxillary  fossa,  and  was  firm  on  section.  The 
cut  surface  was  smooth,  becoming  slightly  granular  after 
prolonged  exposure.  To  the  naked  eye  the  tumour  had  the 
appearance  of  a  malignant  growth.  Under  the  microscope, 
the  juice  scraped  off  the  cut  surface  showed  no  fibrous 
element,  but  simply  a  mass  of  apparently  broken-up  cells 
and  granular  matter. 

On  the  other  hand,  the  disease  may  at  an  early  period 
involve  the  alveolus  and  palate,  or  the  nose,  and  it  is  these 
cases  which  are  sometimes  attributed  to  the  presence  of  de- 
cayed teeth,  or  are  mistaken  for  ordinary  nasal  polypi.  Of 
this,  a  preparation  (College  of  Surgeons'  Museum,  2248), 
which  is  shown  in  fig.  140,  and  was  also  from  a  patient  of 
Mr.  Craven  (to  whom  I  was  indebted  for  both  valuable 
preparations),  is  an  instance.  Here  the  disease  showed  itself 
first  in  the  gums,  where  it   formed  a   fungating  mass,  and 


EOUND-OELLED   SARCOMA. 


305 


soon  olDstracted  the  nostril.  This  last  symptom  was  dae  to 
a  fungus,  almost  papillary  in  appearance,  which  springs 
from  the  nasal  surface  of  the  tumour.     Mr.  Craven  removed 


the  tumour  in  March,  1866,  but  within  a  year  the  disease 
returned  and  proved  fatal. 

The  disease  may  extend  across  the  median  line,  and 
involve  portions  of  both  maxillae,  especially  the  palatine 
plates.  This  is  not  necessarily  a  bar  to  operative  inter- 
ference, provided  other  circumstances  are  favourable,  but 
when  the  disease  exhibits  the  appearance  shown  in  fig.  141, 
the  case  is  obviously  one  beyond  the  aid  of  surgery.  The 
patient,  aged  twenty-four,  was  sent  to  me  in  January,  1868, 
by  Mr.  Harding,  to  whom  he  had  applied  for  the  extraction 
of  some  teeth,  thinking  to  obtain  relief  thereby.  Four  and 
a  half  years  before  he  had  got  a  blow  on  the  face  from  a 
cocoa-nut,  which  broke  the  left  canine  tooth,  and  a  year 
before  I  saw  him,  the  left  side  of  the  face  swelled  up,  but 
subsided  again.  In  August,  1867,  he  first  noticed  a  growth 
below  the  left  eye,  Avhich  rapidly  increased,  but  even  before 
this  the  interior  of  the  mouth  was  tender,  and  felt  swollen 
and    soft    to    the    touch.       He    had    good    advice    in    the 


'^06        MALIGNANT    TUMOUHS    OF    UPPER    JAW. 

country,  and  subsequently  was  in  a  London  hospital,  but 
operative  interference  was  declined  by  the  surgeon  under 
whose  care  he  was.  When  I  saw  him,  some  months  later, 
there  was  a  large  soft  tumour  of  the  left  upper  jaw,  and  a 
smaller  one  on  the  right  side,  which  had  appeared  about 
four  weeks  before.  The  nose  was  considerably  projected  by 
these,  the  left  nostril  being  completely  blocked  and  the  right 
slightly  so.     The   alveolus  was  very  prominent,  so  that  the 

Fig.  141. 


incisor  teeth  sloped  backwards,  and  there  were  soft  masses 
of  disease  on  each  side  of  tlie  palate.  Within  a  week  or 
ten  days  of  my  seeing  the  patient  the  lymphatic  glands  in 
tlie  neck  had  become  enlarged,  particularly  on  the  right 
side,  where  a  considerable  tumour  existed.  This  melancholy 
case  was  obviously  totally  unfitted  for  operation  at  the  time 
I  saw  it,  whatever  might  have  been  its  prospects  at  an  earlier 
date.  I  could  therefore  hold  out  no  hope  of  alleviation  to 
the  unfortunate  patient,  who  returned  to  the  country. 

Eound-celled  sarcoma  occasionally  involves  both  upper 
and  lower  jaws,  beginning,  I  believe,  mostly  in  the  upper 
and  extending  to  the  lower.     Fig.  142  shows  a  good  instance 


ROUND-CELLED  SARCOMA.  307 

of  this  in  a  man  who  was  under  my  care  in  1877,  with  an 
enormous  swelling  of  the  left  side  of  the  face.  I  ventured, 
under  chloroform,  to  introduce  my  finger  into  the  mouth  to 
explore  the  extent  of  the  growth,  but  I  found  it  so  exten- 
sively attached  to  both  upper  and  lower  jaws  that  removal 
was    clearly    impossible.       The    examination    gave  rise  to 

Fig.  142. 


sharp  haemorrhage,  due  to  the  great  vascularity  of  the  growth 
and  this  was  checked  with  some  difficulty  with  the  per- 
sulphate of  iron. 

I  met  with  the  same  implication  of  the  lower  jaw,  though 
to  a  lesser  extent,  in  a  lady,  from  whom  I  removed  the  upper 
jaw  in  consultation  with  Dr.  Csesar,  In  this  case  the  coronoid 
process  was  involved  and  was  removed  with  bone-forceps, 
but  recurrence  of  the  disease  took  place  and  the  patient  did 
not  survive  the  operation  four  months. 

JEpithelioma  occurs  in  the  upper  jaw  in  two  forms,  the 
squamous  and  columnar  ;  and  the  former,  which  always 
begins  in  the  gum  or  palate,  has  already  been   described 

x2 


308  MALIGNANT    TUMOURS    OF    UPPER    JAW. 

(p.  257)  in  connection  with  the  antrum.  Cohimnar  epithe- 
lioma always  begins  in  the  antrum,  which  it  often  fills,  and 
then  secondarily  involves  the  palate  ;  or  it  may  attack  the 
outer  wall  only  of  tlie  antrum,  and  then  protrude  on  the 
face.  Occurring  usually  in  patients  over  forty  years  of  age, 
the  disease  begins  very  insidiously,  the  patient  complaining, 
perhaps,  of  neuralgia  or  of  nneasiness  in  the  face,  but  of  little 
more.  When  the  antrum  has  become  distended,  the  epithe- 
lioma is  apt  to  involve  the  palate  by  absorption  and  eventual 
f  ungation^  and  then  protrude  into  the  nostril  and  orbits.  In 
the  Museum  of  the  College  of  Surgeons  is  a  preparation 
(2235)  of  the  right  superior  maxilla,  with  a  soft  white 
tumour  filling  the  antrum  and  protruding  into  the  nose  and 
orbit,  which  I  removed  from  a  gentleman  aged  fifty-one,  who 
five  years  before  the  ojoeration,  noticed  "  lumps  in  the  hard 
palate,"  which  were  lancedj  but  never  healed,  though  appear- 
ing to  diminish  in  size.  About  four  years  later  his  right 
nostril  became  blocked,  and  there  was  protrusion  of  the  eye. 
I  removed  the  jaw  very  freely,  but  recurrence  took  place  at 
the  back  of  the  orbit,  and  it  became  necessary  to  remove  the 
eyeball  in  order  to  clear  out  the  growth  effectually,  but  even 
now  it  is  not  certain  that  a  cure  has  been  effected. 

The  morbid  growth  in  this  case  is  unattached  to  the  wall 
of  the  antrum,  except  behind,  where  it  extends  into  the 
substance  of  the  gums  and  palate.  Mr,  Eve's  microscopic 
examination  sliows  it  to  consist  of  closely  packed  and  very 
tortuous  columns  of  small  round  epithelium  ;  a  few  of  them 
had  a  lumen,  around  wliicli  tlie  cells  were  arranged  in  a 
regular  manner,  as  in  tubular  glands.  The  stroma  was  com- 
posed of  sarcomatous  tissue.  This  case  is  one  of  unusual 
duration  for  an  example  of  pure  epithelioma,  and  the  fact 
that  the  tumour  is  a  mixture  of  epithelioma  and  sarcoma 
probably  gives  the  clue  to  it,  although  the  suljsequent  history 
is  distinctly  that  of  epithelioma. 

The  more  usual  rapidity  of  growth  (^f  ei)ithelioma  of  the 
upper  jaw  is  well  illustrated  by  a  case  I  attended  witli  Mr. 
Sams,  of  Blackheath,  in  the  latter  part  of  1871.  A  lady 
aged  fifty-two,  had  noticed  a  small  growth  in  the  gum  of  the 


EPITHELIOMA    OF    UPPER   JAW.  309 

left  upper  jcaw,  which  gradually  overlapped  the  hard  palate. 
This  was  removed  by  another  surgeon  in  May,  1871,  but  the 
growth  reappeared  almost  immediately.  In  November  I 
found  a  fungus-looking  mass  involving  the  greater  part  of 
the  left  half  of  the  hard  palate,  the  bone  of  which  was 
absorbed,  and  bulging  up  beneath  the  cheek.  I  removed  the 
left  half  of  the  hard  palate,  with  the  whole  of  the  growth,  on 
November  24.  In  ten  days  the  growth  reappeared  on  the 
apparently  healthy  section  of  the  hard  palate  and  also  in 
the  cheek.  A  fortnight  after  the  first  operation  I  therefore 
again  operated  very  freely,  applying,  as  on  the  former 
occasion,  a  strong  solution  of  the  chloride  of  zinc  to  the 
entire  wound.  Again,  within  ten  days,  the  disease  reap- 
peared and  rapidly  filled  up  the  cavity  left  by  the  operation, 
blocking  the  nostril  and  mouth,  and  eventually  suffocating 
the  patient  in  lier  sleep,  on  December  29. 

Even  when  the  disease  is  far  advanced,  however,  so  that 
the  tissues  of  the  face  and  mouth  are  much  involved,  it  is 
sometimes  possible  for  the  surgeon  to  give  relief,  if  not  per- 
manent cure,  by  completely  excising  the  morbid  structures. 

A  case  intermediate  betw^een  the  two  foregoing  in  rapidity, 
and  illustrating  the  advantage  of  operating  in  cases  of  epi- 
thelioma where  a  cure  cannot  be  hoped  for,  was  under  my 
care  during  1882-3.  A  lady,  aged  fifty-tw^o,  was  sent  to  me 
in  March,  1882,  by  Sir  Spencer  Wells,  with  the  foUoAving 
history: — A  month  before  Christmas,  1881,  she  had  noticed 
a  swelling  of  the  left  cheek,  and  when  I  saw  her  had  a 
uniformly  elastic  swelling  involving  the  left  upper  jaw,  and 
spreading  up  the  margin  of  the  left  orbit.  The  skin  was 
tense  and  reddened,  but  not  involved  apparently,  and  the 
palate  was  healthy.  I  recommended  removal,  with  the  view 
of  prolonging  life,  and  in  this  view  Mr.  Erichsen  coincided, 
but  two  eminent  surgeons  had  given  a  contrary  opinion. 

On  March  24  I  turned  back  a  flap  of  the  cheek,  and  found 
the  tumour  well  covered  with  fascia  and  the  skin  healthy. 
I  opened  the  temporal  fascia,  so  as  to  isolate  the  growth 
behind,  and  divided  the  zygoma  afterwards,  clearing  the 
malar  bone,  and  sawing  the  external  angular  process  of  the 


310         MA.LIGNANT    TUMOUES    OF    UPPER   JAW. 

frontal  bone.  Tlie  palate  was  then  sawn  through,  and  the 
jaw  readily  removed.  The  remains  of  the  hard  palate  were 
removed  with  bone-forceps  quite  up  to  the  pterygoid  process, 
which  was  healthy,  and  the  parts  were  freely  cauterized  to 
make  doubly  sure.  The  patient  made  a  good  recovery,  and 
left  town  much  relieved  on  April  19. 

In  September  I  saw  her  again,  w^hen  there  was  an  epi- 
theliomatous  fungus  at  the  outer  angle  of  the  wound 
measuring  IJ  inches  across.  No  glands  were  enlarged,  and 
the  patient's  health  continued  good.  On  September  28,  I 
removed  the  growth  and  surrounding  skin  freely  with 
Paquelin's  cautery,  and  applied  chloride  of  zinc  paste.  The 
mouth  and  cavity  left  by  removal  of  the  upper  jaw  were 
quite  healthy,  but  the  mouth  could  not  be  opened  freely 
because  the  surface  of  the  lower  jaw  had  become  involved 
by  the  disease  in  the  cheek.  On  October  10  a  recurrence 
of  disease  at  the  bottom  of  the  otherwise  healthy  wound  was 
noticed,  and  the  caustic  paste  was  re-applied. 

In  November  the  patient  returned  with  one  small  spot  of 
epithelioma  at  the  bottom  of  the  wound,  involving  the 
mucous  membrane  of  the  mouth.  This  was  thoroughly 
destroyed  with  caustic  paste,  and  the  parts  .were  quite  sound 
when  the  patient  went  home.  In  February,  1883,  there 
was  a  fresh  recurrence  in  the  cheek,  but  the  patient  was  too 
weak  to  bear  treatment,  and  she  died  in  April,  having  sur- 
vived the  first  operation  more  than  a  year  in  comparative 
comfort,  and  with  no  formidable  external  tumour. 

The  preparation  from  this  case  (College  of  Surgeons' 
Museum,  2246)  shows  a  growth  springing  from  the  mucous 
membrane  of  the  antrum,  which  in  places  is  ragged  and  has 
a  papillary  appearance.  Mr.  Eve  reported  that  under  the 
microscope  the  mucous  membrane  of  the  antrum  was  ob- 
served to  be  exceedingly  thickened  by  an  overgrowth  of 
epithelium,  for  the  most  part  of  an  elongated  form. 

This  condition  corresponds  very  closely  to  that  of  another 
upj)er  jaw  removed  by  me  in  1866,  and  now  in  the  Museum 
of  the  College  of  Surgeons  (2247  A.),  which  in  former 
editions  of  this  work  I  described  as  an  example  of  "  fibroid 


EPITHELIOMA    OF    UPPER    JAW. 


311 


disease,"  but  which  is,  I  believe,  really  epitheliomatous.  In 
September,  1866,  Dr.  Whitmarsh,  of  Hounslow,  brought  to 
me  a  gentleman  who,  two  years  before,  had  perceived  some 
growth  in  the  right  nostril,  which  gave  no  pain,  but  kept  up 
a  constant  discharge,  esj^ecially  at  night.  In  the  early  part 
of  the  year  this  had  been  removed  in  part  by  a  surgeon,  and 
since  that  the  discharge  had  much  increased.  There  was  a 
fungous  growth  in  the  right  nostril,  and  the  whole  right 
maxilla  was  swollen  and  discharged  thin  pus  at  one  or  two 
points  near  the  eye.  There  was  a  fungous-looking  growth 
in  the  molar  region,  and  a  probe  passed  by  its  side  into  the 
antrum. 

I  removed  the  disease  on  September  23,  clearing  away 
the  whole  of  the  growth,  which  was  very  friable,  and 
leaving  the  posterior  wall  of  the  antrum  and  the  infra- orbital 
plate  untouched.  In  the  course  of  the  operation  I  found  a 
distinct  polypoid  growth  filling  the  posterior  nares,  which  I 
removed.  The  patient  rallied  well  from  the  operation,  but 
unfortunately  got  congestion  of  the  lungs  and  died  on  the 
fifth  day. 

The  preparation  is  in  the  College  of  Surgeons'  Museum 
(1052  B),  and  the  appearance  of  a  part  of  the  disease  is 
shown  in  fig.  143.     It  will  be  seen  that  the  interior  of  the 

Fig.  143. 


antrum  is  covered  with  a  remarkable  papillary  or  villous 
growth,  resembling  some  forms  of  cauliflower  excrescence.  A 
quantity  of  broken-down  loose  fibroid  tissue  lies  at  the  bottom 
of  the  bottle  of  the  preparation^  and  a  portion  of  it,  with 
the  adjacent  mucous  membrane,  is  given  in  the  sketch  ;  the 


312         MALIGNANT    TUMOURS    OF    UPPER   JAW. 

other  portion  being  the  polypoid  growth  extracted  from  the 
posterior  nares.  Mr.  Bruce  favoured  me  with  the  follow- 
ing report  upon  the  specimen : — 

"  It  appears  to  consist  of  a  fine  soft  fibrous  stroma,  in 
which  very  numerous  nuclear  bodies  and  a  few  elongated 
fibre  cells  are .  distributed.  Its  structure  resembles  that  of 
the  upper  strata  of  a  mucous  membrane,  from  which  it  is 
probably  an  outgrowth." 

I  have  at  present  under  my  care  a  very  interesting  case 
of  ei^ithelioma,  beginning  in  the  outer  plate  of  the  upper  jaw 
in  an  otherwise  healthy  man,  aged  fifty-three,  who  in  October, 
1882,  came  into  University  College  Hospital  with  a  swelling 
of  the  right  cheek  about  1^  inches  broad,  extending  from 
the  nose  to  the  zygoma,  and  clearly  connected  with  the 
superior  maxilla.  The  mouth  and  nostril  were  in  no  way 
involved,  and  I  therefore  determined  to  remove  only  the 
part  of  the  maxilla  affected — viz.,  its  anterior  surface.  This 
I  did  by  reflecting  the  skin  and  prolonging  the  infra-orbital 
incision  to  the  malar  bone,  which  I  sawed  through.  Then 
dividing  the  nasal  process,  I  was  able  to  break  away  the 
anterior  wall  of  the  antrum  with  the  tumour,  leaving  the 
palate  untouched.  The  tumour  was  3  inches  long  and  2 
broad,  and  grew  from  the  outer  wall  of  the  antrum,  which  it 
had  not  penetrated.  The  substance  of  the  growth  was  of  a 
faint  pinkish  colour,  very  firm,  and  not  lobulated,  and  micro- 
scopically was  thought  to  be  a  myxo-sarcoma  (?). 

The  patient  made  a  rapid  recovery  and  remained  in  good 
health  for  three  months,  when  he  noticed  a  fulness  above 
the  malar  bone,  which  increased  until  his  re-admission  at  the 
end  of  March.  It  was  then  found  that  the  upper  margin  of 
the  malar  bone,  the  zygomatic  arch,  and  the  lower  part  of  the 
temporal  fossa  were  all  obscured  by  a  firm  growth,  the  skin 
over  it  being  slightly  reddened  and  fairly  movable.  On 
March  29,  1883,  I  exposed  the  new  growth  and  isolated  the 
bone  to  which  it  was  attached,  by  dividing  the  zygoma  far 
back  and  the  external  angle  of  the  frontal  bone ;  but  on 
breaking  the  malar  bone  away  with  the  tumour  I  found  that 
the  antrum  was  now  filled  with  new  growth,  and  therefore 


EPITHELIOMA    OF    UPPEJl   JAW.  313 

removed  the  superior  maxilltc  in  the  usual  way,  afterwards 
applying  caustic  paste  to  the  exposed  surface.  The  soft 
material  now  filling  the  antrum  was  clearly  epitlieliomatous. 
The  patient  again  made  a  good  recovery,  hut  in  June  it 
became  necessary  to  remove  the  eyeball,- which  had  suppu- 
rated. In  November  the  patient  again  presented  himself 
with  a  perfectly  healthy  cicatrix  in  the  mouth  and  wearing 
an  artificial  palate,  but  with  the  lower  and  part  of  the 
upper  eyelids  infiltrated  with  epithelioma  which  had  sprung 
up  in  the  neighbourhood  of  the  old  cicatrix  below  the  eye. 
This  I  removed  freely  with  Paquelin's  cautery,  and  subse- 
quently applied  caustic  paste  freely,  the  disease  being 
entirely  outside  the  cavity  of  the  mouth. 

In  some  cases  of  epithelioma  it  is  impossible  at  the  time 
of  the  operation  to  remove  the  whole  of  the  disease.  Of 
this  an  example  will  be  found  in  the  Appendix  (Case  XI.), 
where  the  tissues  of  the  orbit  were  found  to  be  extensively 
involved.  This  case  also  illustrates  the  fatal  consequences 
to  which  elderly  and  feeble  patients  seem  specially  liable 
after  operations  on  the  mouth — viz.,  to  a  low  form  of  broncho- 
pneumonia, by  some  considered  to  be  septic  in  its  nature, 
which  is  rapidly  fatal.  The  careful  record  of  the  post- 
mortem examination  of  this  patient  by  Mr.  Barker  gives  a 
typical  example  of  the  pathology  of  this  disorder. 


314 


CHAPTER  XXI. 

DIAGNOSIS    AND    TREATMENT   OF  TUMOURS   OF   THE  UPPER  JAW. 

The  diagnosis  of  tumours  of  the  upper  jaw  is  by  no  means 
simple.  Even  the  distinction  between  fluid  tumours  due 
to  cystic  enlargement  of  the  jaw  and  solid  growths,  is,  as 
has  abeady  been  pointed  out,  not  always  easy;  and  it  is  stiU 
more  difficult,  and  in  some  cases  impossible,  to  decide  as  to 
the  malignancy  or  otherwise  of  a  tumour  previous  to  its 
extirpation. 

The  fibrous,  cartilaginous,  and  osseous  tumours  are  all  of 
slow  growth,  painless,  and  more  or  less  hard  to  the  touch. 
They  do  not  affect  the  general  health,  nor  do  they  show  any 
tendency  to  involve  the  surrounding  tissues  o"^  the  skin, 
except  by  mechanical  interference.  The  tibro-sarcomatous 
and  myeloid  tumours  are  more  rapid  in  their  growth,  and 
softer  than  those  already  mentioned ;  both  are  more  vascular 
in  appearance  at  points  where  they  are  covered  only  by 
mucous  membrane.  They  occasionally  ulcerate,  but  do  not 
fungate,  and  may,  under  these  circumstances,  discharge 
blood  in  considerable  quantities.  The  medullary-sarcoma- 
tous  and  epitheliomatous  tumours  are  the  most  rapid  in  their 
growth,  and  their  tendency  to  involve  suri-ounding  structures 
is  early  manifested.  Its  softness  and  tendency  to  fungate 
are  the  chief  characteristics  of  ej)ithelioma,  but  these  must 
not  be  relied  on  too  implicitly.  This  last  variety  is  ordinarily 
more  painful  than  the  others,  the  patient  frequently  com- 
plaining of  neuralgic  or  gnawing  pains  in  the  head  and  face. 

In  examining  a  case  of  tumour  of  the  uj)per  jaw,  a  careful 
inspection  should  l)c  made  of  tlic  face,  mouth,  and  nares. 
The  consistency  of  the  projection  beneath  the  cheek  should 


OPERATIONS    ON  THE   UPPER    JAW.  315 

be  tested  with  the  finger  both  outside  and  inside  the  cheek 
itself.  The  condition  of  the  hard  and  soft  palate  should  be 
particularly  investigated,  and  the  finger  should  be  carried 
behind  the  soft  palate,  if  there  is  any  suspicion  that  the 
tumour  extends  towards  the  posterior  nares.  The  removal 
of  a  tooth  may  assist  in  the  diagnosis^  either  by  evacuating 
fluid,  or  by  bringing  away  with  it  a  small  portion  of  growth 
which  may  be  submitted  to  microscopic  examination.  The 
condition  of  the  nostril  will  require  esj)ecial  examination, 
particularly  in  those  cases  where  the  disease  shows  itself  at 
an  early  period  in  that  cavity,  and  doubt  arises  as  to  its 
nature.  The  careful  introduction  of  a  probe  whilst  a  good 
light  is  thrown  into  the  nostril,  will  enable  the  surgeon  to 
decide  whether  the  tumour  is  merely  a  polypus  springing 
from  the  turbinate  bones,  or  whether  it  is  a  portion  of  an 
antral  tumour  showing  itself  in  the  nostril,  or  possibly  some 
growth  springing  from  the  base  of  the  skull  and  simulating 
maxillary  disease. 

Prognosis. — But  little  can  be  hoped  from  medicine  in  the 
treatment  of  tumours  of  the  upper  jaw.  The  application  of 
iodine  has  been  said  by  Mr.  Stanley  to  have  affected  the 
removal  of  a  small  enchondroma,  and  no  harm  will  be  done 
by  resorting  to  such  measures  and  to  the  internal  adminis- 
tration of  absorbent  medicines,  for  a  short  time  whilst  the 
progress  of  the  disease  is  watched,  provided  no  chemical 
agent  be  applied  to  the  growth  itself,  by  which  it  might  be 
irritated  or  caused  to  inflame.  Eemoval  by  surgical  opera- 
tion is,  however,  the  only  effectual  means  of  treatment,  and 
the  sooner  an  operation  is  undertaken  the  better  in  all  cases, 
since  even  a  benign  tumour  may,  by  its  size  or  by  its  attach- 
ments, put  a  patient's  life  in  danger  if  allowed  to  grow 
unchecked  for  a  series  of  years.  In  malignant  disease  the 
only  hope  for  the  patient  is  early  and  complete  removal, 
whilst  the  disease  is  confined  to  the  bone  and  before  the 
surrounding  structures  have  become  affected. 

Operations  on  the  Upper  Jaw. — From  early  times  portions 
of  the  upper  jaw,  and  particularly  the  alveolus,  were  occa- 
sionally removed  on  account  of  some  disease,  and  with  more 


31G  OPERATIONS    ON    THE    UPPER   JAW. 

or  less  permanent  success.  Mr.  Butcher,  who  has  labo- 
riously investigated  the  subject,  puts  the  earliest  case  in  1693, 
the  operator  being  Akoluthus,  a  physician  at  Breslau.  De- 
sault,  (Jarengeotj  Jourdain,  and  others  in  the  last  century 
removed  growths  from  the  jaw,  gonging  them  out  with 
chisels  with  partial  and  temporary  success ;  and  Dupuytren 
especially  advocated  this  mode  of  treatment  in  his  "  Le90us 
Orales,"  and  frequently  practised  it,  removing  in  this  manner 
the  greater  part  of  the  npper  jaw  in  1824.  Charles  White, 
of  Manchester,  appears  also  to  have  successfully  operated  on 
a  patient,  from  whom  he  removed,  piecemeal,  nearly  the 
whole  of  the  upper  maxilla  during  the  last  century. 

The  late  Mr.  John  Lizars,  of  Edinbiu'gh,  appears  to  have 
been  the  first  to  propose  removal  of  the  entire  superior 
maxilla  as  a  whole  in  1826,  when,  in  his  "  System  of  Ana- 
tomical Plates,"  he  showed  how,  anatomically,  it  would  be 
possible   to  remove  the   bone  without  injury  to   important 

Fig.  144. 


and  vital  parts,  and  recommended  the  previous  deligation 
of  the  common  carotid  artery,  with  a  view  of  preventing 
haemorrhage.  Mr.  Lizars  did  not  have  an  opportunity  of 
carrying  his  proposition  into  effect  until  December,  1827, 
when,  notwithstanding  the  ligature  applied  to  the  carotid, 
the  hsemorrhage  was  so  fearful  as  to  necessitate  a  discon- 
tinuance of  the  operation  {Lancet,  1829-30).  M.  G ensoul, 
of  Lyons,  had,  however,  forestalled  Mr,  Lizars  quite  inde- 
pendently and  without  being  aware  of  his  proposition,  for 


OPERATIONS    ON    THE    UPPER    JAW. 


317 


in  May,  1827,  he  removGcl  the  entire  superior  maxillary  bone, 
with  a  part  of  the  palate,  from  a  boy  of  seventeen,  on 
account  of  a  larsje  fibro-cartilaoinous  tumour.  The  incision 
employed  by  G-ensoul  (fig,  141*)  was  a  vertical  one  from  the 
corner  of  the  eye  to  the  lip,  joined  midway  at  right  angles 
by  a  transverse  incision,  which  was  again  met  by  a  small 
vertical  incision  ascending  to  the  malar  bone.  By  the  em- 
ployment of  the  mallet  and  chisel  the  jaw,  with  the  tumour, 
was  dislodged  and  removed  by  the  division  of  the  palate. 
Although  the  carotid  was  not  tied  the  hcemorrhage  was  not 
very  great,  and  the  patient  recovered. — {Lcttre  Qhirurgicale 
SUV  quelques  Maladies  Graves  du  Sinus  Maxillairc,  par  A. 
Gensoul). 

Mr.  Syme  operated  successfully  in  May,  1829  {Edinhirgh 
Medical  and  Surgical  Journal,  1829),  and  Mr.  Lizars  also 
operated  again  in  1829,  for  a  medullary  tumour,  which  was 
completely  removed  with  the  exception  of  a  small  portion 
attached    to    the    pterygoid   processes.       The    patient    had 


FiGt.  145. 


Fig.  146. 


become  quite  convalescent,  when  she  died  suddenly  on  the 
nineteenth  day  {London  Medical  Gazette,  \o\.  v.  p.  92). 
His  third  and  successful  operation  was  in  1830  {Lancet, 
1829-30),  and  from  that  time  removal  of  the  upper  jaAV 
became  an  established  operation  in  surgery.  Mr.  Lizars 
used  an  incision   across  the  cheek  from  the  angle  of  the 


318 


OPERATIONS    ON   THE    UPPER   JAW. 


mouth  to  the  malar  bone  (fig.  145),  or  when  the  tumour 
was  very  large,  employed  in  addition  an  incision  through 
the  lip  into  the  nostril,  with  a  vertical  cut  at  the  malar 
bone  (fig.  146).  With  the  saw  and  bone-forceps  the  maxilla 
was  separated  from  its  attachments  and  removed. 

Lizars'  example  was  followed  by  most  of  the  leading 
surgeons  of  the  day,  but  Mr.  Liston  requires  especial  notice, 
since  he  performed  some  of  the  earliest  and  most  important 
operations  of  the  kind,  and  in  his  essay,  which  has  been 
frequently  referred  to  {Medico-Chirurgiccd  Transactions, 
vol.  XX.),  brought  the  subject  and  its  relations  to  various 
forms  of  disease  prominently  under  the  notice  of  the  pro- 
fession. Mr.  Liston  seems  to  have  been  strongly  impressed 
with  the  notion  that  malignant  disease  of  the  jaw  should 
not  be  interfered  with,  but  this  idea  does  not  prevail  among 
operating  surgeons  of  the  present  day,  for  it  is  felt  that  it 


Fig.  147. 


is  better  to  act  upon   the   principle  which  guides  operations 
upon  cancerous  growths  in  other  parts    of  the    body — to 


OPERATIONS    ON    THE    UPPER   JAW. 


319 


remove  the   growths,  if  feasible,  in   the   hope   of  giving  at 
least  relief  if  not  a  permanent  cure. 

Syme,  Mott,  Velpeau,  Dieffenbach,  O'Shaughnessy,  Hey- 
felder,  Fergusson,  and  Butcher  may  be  mentioned  as  having 
performed  the  operation  of  excision  of  the  superior  maxilla 
repeatedly  and  successfully,  and  to  Sir  William  Fergusson 
especially  is  due  the  proposal  of  modifications  of  the  greatest 
moment  in  the  method  of  procedure.  Noticing  the  con- 
siderable deformity  resulting  from  an  incision  from  the 
angle  of  the  mouth,  which  necessarily  divides  the  facial 
nerve  (fig.  147),  and  still  more  when  a  flap  of  skin  has 
been  reflected  from  the  face  by  a  double  incision  (fig.  56), 
Sir  William   Fergusson  devised    the  plan  of  carrying  the 

Fiti.  148. 


incision  solely  through  the  median  line  of  the  lip  into  the 
nostril.  By  dissecting  up  the  tissues  of  the  nose  and  taking 
advantage  of  the  stretching  of  the  skin  of  the  nostril,  room 
may  thus  be  obtained  for  the  removal  of  any  tumour  not  of 
large  size ;    but  supposing    this  to  be  found  impracticable, 


320 


OPERATIONS   ON   THE   UPPER   JAW. 


it  is  still  open  to  the  operator  to  prolong  the  incision  round 
the  ala  and  up  the  side  of  the  nose,  and  in  the  case  of  large 
tumours,  to  carry  it  in  a  curve  below  the  orbit  to  the  malar 
bone,  as  seen  in  fig.  148.  The  great  advantages  of  these 
methods  are  that  the  facial  nerve  and  facial  artery  are 
divided  at  points  where  their  size  is  of  no  consequence,  and 
consequently  the  loss  of  blood  and  the  subsequent  deformity 
are  much  diminished ;  and  also  that  the  scars  fall  in  such 
positions  as  to  be  hardly  noticeable. 

The  method  of  proceeding  which  I  recommend  when  it  is 
necessary  to  remove  the   entire  upper  jaw  is  as  follows  : — 


Fifi.  149. 


Fio.  150. 


The  skin  having  been  reflected  in  the  manner  described 
above,  the  incisor  teeth  of  the  side  to  be  removed  are  ex- 
tracted and  a  narrow  saw  with    a  movable  back  passed  into 


REMOVAL   OF   THE    UPPER   JAW.  321 

the  nostril.  With  this  the  alveohis  and  hard  palate  are 
divided,  and  a  small  saw  (fig.  149)  is  then  applied  to  the 
malar  boue  in  a  line  with  the  spheno- maxillary  fissure,  and 
to  the  nasal  process  of  the  superior  maxilla,  so  as  to  notch 
both  these  points  of  bone,  the  division  being  completed 
with  the  bone-forceps.  With  the  "  lion-forceps,"  devised 
by  Sir  William  Fergusson  for  the  purpose  (fig.  150),  the 
jaw  can  now  be  grasped  and  broken  away  from  the  pterygoid 
process  and  palate  bone,  any  detaining  point  being  severed 
with  the  bone-forceps.  Lastly,  when  the  bone  is  quite  loose, 
the  infra-orbital  nerve  is  to  be  severed,  and  the  soft  palate 
divided  at  its  attachment  to  the  bone,  so  as  to  leave  as 
much  of  it  as  possible  uninjured,  and  any  remaining  portions 
of  disease  are  then  to  be  removed  with  the  bone-forceps 
and  gouge.  Ha3morrhage  is  to  be  arrested  by  ligatures  and 
the  application  of  the  actual  cautery  to  the  deep  tissues,  and, 
finally,  the  lip  and  incision  are  to  be  brought  together  and 
carefully  adjusted  with  hare-lip  pins  and  interrupted  sutures 
of  fine  wire  or  silk. 

"Wlien  the  disease  is  of  less  amount,  and  the  orbital  plate 
is  not  involved,  this  should  be  preserved  by  carrying  a  saw 
horizontally  below  it ;  and  if  the  palate  is  not  involved,  this 
may  be  advantageously  kept  intact  by  making  a  similar  cut 
immediately  above  it.  Under  these  circumstances  the  inci- 
sions through  the  skin  need  only  be  very  limited,  and  the 
bone-forceps  and  gouge  will  be  requisite  to  clear  out  all  the 
disease  from  the  antrum. 

Sir  William  Fergusson  has,  in  his  "  Lectures  on  Anatomy 
and  Surgery,"  strongly  urged  the  pursuance  of  a  less  heroic 
plan  than  that  which  has  hitherto  been  followed,  in  going 
completely  beyond  and  not  interfering  with  the  diseased 
tissues.  According  to  that  eminent  surgeon,  it  is  better  to 
cut  into  the  disease  and  to  clear  it  out  by  working  from  the 
centre  to  the  circumference,  so  as  not  to  remove  healthy 
structures  unnecessarily,  and  this  may  be  accomplished  by 
means  of  curved  and  angular  bone-forceps  of  various  sizes, 
and  by  the  use  of  the  gouge.  Mr.  Syme  {British  Medical 
Journal,  Aug.  13,  1865)  denounced  this  method  as  a  return 

Y 


322  OPERATIONS    ON    THE    UPPER   JAW. 

to  "  the  old  system  with  its  cliisels  and  gouges ;"  but  the 
practice,  as  regards  non-cancerous  tumours  at  least,  has 
recently  received  the  strong  support  of  Sir  James  Paget,  who 
in  a  paper  in  the  Medico- Chirurgical  Transactions,  vol.  liv., 
has  urged  the  propriety  of  enucleating  simple  tumours 
growing  in  the  interior  of  bones,  and  among  other  cases 
gives  one  of  a  lad  of  nineteen,  from  whose  antrum  he  sue- 
cessfully  removed  a  large  mass  without  injury  to  the  palate 
or  orbit,  A  similar  instance,  under  my  own  care,  is  given 
at  p.  267.  The  case,  is,  however,  different  when  the  disease 
is  of  a  malignant  character,  and,  after  some  considerable 
experience,  I  am  decidedly  of  opinion  that  the  surgeon  must 
go  well  beyond  the  boundaries  of  the  tumour  if  he  hopes  to 
give  the  patient  permanent  relief.  The  practice  of  cutting 
into  a  malignant  growth  gives  rise  to  considerable  haemor- 
rhage, which  renders  it  very  difficult  to  be  certain  as  to  the 
removal  of  the  entire  disease.  It  is  better,  therefore,  1 
think,  to  cut  into  the  healthy  bone  beyond,  so  as  to  be  quite 
certain  of  removing  the  entire  growth,  though  it  is  by 
no  means  necessary  to  remove  large  portions  of  healthy 
structure. 

In  cases  of  epithehoma,  where  even  the  whole  of  the 
diseased  structures  have  been  removed,  I  would  strongly 
advise  the  application  of  the  chloride  of  zinc  paste,  made 
with  hydrochloric  acid  and  opium,  after  the  formula  of  the 
Middlesex  Hospital.  Applied  on  the  end  of  a  strip  of  lint 
to  the  doubtful  part,  the  rest  of  the  lint  can  be  packed  in 
and  covered  over  with  a  pledget  of  cotton-wool,  so  as  to 
prevent  the  escape  of  the  chloride  of  zinc  into  the  mouth ; 
and  I  have  found  it  very  advantageous  to  plug  the  posterior 
nostril  on  the  affected  side  from  the  fi'ont  with  another 
strip  of  lint,  so  as  to  obviate  the  escape  of  fluid  into  the 
throat.  After  three  days  the  plugs  are  easily  withdrawn 
from  beneath  the  cheek,  and  free  syringing  will  keep  the 
parts  sweet  while  the  sloughs  caused  by  the  caustic  are 
separating.  For  washing  out  the  mouth  there  is  nothing 
better  than  the  syphon  nasal-douche  with  a  soft  nipple. 

In  cases  of  epithelioma  in  which  the  skin  is  involved,  the 


LIGATURE   OF   THE   CAROTID    ARTERY.  .S23 

portion  so  diseased  must  be  sacrificed  if  a  cure  is  to  be 
hoped  for.  This  may  be  effected  with  the  knife  or  the 
actual  cautery,  and  I  may  refer  to  a  very  successful  example 
of  this  method  of  treatment  by  Mr.  Lawson,  recorded  in  the 
Clinical  Society's  Transactions,  vol.  vi. 

As  a  local  antiseptic  nothing  is  equal  to  powdered  iodo- 
form, freely  applied  to  the  raw  surfaces  both  of  bone  and  soft 
parts.  In  this  way  the  cavity  left  by  removal  of  the  upper 
jaw  may  be  kept  sweet  for  days  after  the  operation,  and  the 
patient  be  spared  the  risks  of  purulent  infection  or  septic 
bronchitis. 

It  has  been  mentioned  that  in  the  earlier  operations  for 
removal  of  the  upper  jaw,  it  was  customary  to  apply  a  liga- 
ture to  the  common  or  external  carotid  artery.  Although 
this  practice  has  now  been  quite  abandoned,  it  has  in  a  few 
cases  been  necessary  to  secure  the  main  vessel  after  the  ope- 
ration, on  account  of  secondary  haemorrhage.  Thus  Mr. 
Field,  of  Brighton,  tied  the  common  carotid  two  days  after 
removal  of  the  upper  jaw,  in  1858,  and  the  patient  recovered 
{Medical  Times  and  Gazette,  Aug.  28,  1858).  In  a  patient 
of  Mr.  Holmes  Coote,  at  St.  Bartholomew's,  in  1866,  the 
house-surgeon,  Mr.  Orton,  tied  the  vessel  on  the  nineteenth 
day,  but  the  patient  sank  {Lancet,  Oct.  13,  1866).  In  his 
recent  work  on  Cancer,  Mr.  0.  Pemberton  mentions  a  case 
which  occurred  in  1848,  when  he  was  house-surgeon  at  the 
Birmingham  General  Hospital,  which  also  proved  fatal. 

As  a  rule,  however,  patients  who  have  been  submitted  to 
removal  of  the  upper  jaw  recover  with  wonderful  rapidity. 
Of  course  the  primary  shock  of  such  an  operation  is  severe, 
but  when  this  is  once  got  over  the  convalescence  is  ordi- 
narily rapid. 

Eemoval  of  hoth  upper  jaws  has  occasionally  been  per- 
formed. A  case  in  which  Mr.  Lane  removed  the  greater 
part  of  both  jaws  has  been  referred  to  in  this  essay  (p.  288), 
and  the  operation  has  been  performed  by  Eogers,  of  Xew 
York  (1824),  Heyfelder  (1844,  and  twice  afterwards),  Dief- 
fenbach,  Maisonneuve,  and  others.  Heyfelder  made  two 
incisions  from  the  outer  angles  of  the  eyes  to  the  corners  of 

Y   2 


324  OPERATIONS   ON   THE   UPPER  JAW. 

the  mouth,  and  reflected  this  quadrilateral  flap  to  the  fore- 
head, taking  the  nose  with  it.  He  then  passed  a  chain-saw 
through  the  spheno-maxillary  fissure  on  each  side,  and  thus 
separated  the  jaws  and  the  malar  bones.  The  junctions 
with  the  nasal  bones  and  vomer  were  then  divided  with  bone- 
forceps,  and  the  soft  palate  separated  from  the  margin  of  the 
hard.  Lastly,  powerful  traction  upon  the  bones  was  exerted, 
and  the  bones  were  displaced.  Dieffenbach,  Maisonneuve, 
and  others,  employed  a  median  incision,  beginning  at  the 
root  of  the  nose  and  ending  in  the  median  line  of  the  lip,  so 
as  to  divide  tlie  skin  of  the  face  into  two  lateral  flaps.  This 
appears  an  unnecessary  complication  however,  since  division 
of  the  lip  and  free  dissection  of  the  nostrils  would  afford 
sufficient  room  for  the  removal  of  the  jaw  in  two  halves.  A 
paper  on  Total  Double  Eesection  of  the  Upper  Jaws,  by 
H.  Braun,  of  Heidelberg,  will  be  found  in  Langenbeck's 
Archiv,  xix.  1876. 

In  1872,  Mr.  Dobson,  of  Bristol,  removed  both  superior 
maxillfc  of  a  woman,  aged  fifty-two,  by  dividing  the  lip  in 
the  middle  line  and  carrying  an  incision  up  each  side  of  the 
noee  {British  Medical  Journal,  Oct.  11,  1873),  and  Mr. 
Bellamy  informs  me  that  he  has  recently  removed  the  greater 
part  of  both  upper  jaws  by  simply  reflecting  the  lip  with- 
out any  external  incision. 

Dr.  Cliarles  Brigham,  of  San  Francisco,  has  reported  in 
his  *'  Surgical  Cases  with  Illustrations"  (1876),  an  instance 
of  successful  removal  of  the  entire  upper  jaw  for  malignant 
disease,  after  performing  tracheotomy  and  plugging  the 
pharynx  with  sponge.  In  a  case  of  such  extensive  disease 
the  preliminary  tracheotomy  was,  no  doubt,  admirable,  but 
for  ordinary  cases  of  removal  of  tumours  of  the  upper  jaw  the 
proceeding  seems  to  me  uncalled  for,  as  I  have  never  em- 
ployed it,  and  have  only  seen  it  employed  on  one  occasion. 
Professor  Trendelenburg's  proposal  to  perform  a  preliminary 
tracheotomy,  and  to  plug  the  trachea  by  a  special  expanding 
tampon  in  all  serious  operations  about  the  mouth,  was  made 
in  1871,  and  will  be  found  described  at  length  in  t\\Q  Medical 
Times  and   Gazette  for  May,  1872,     I  have  employed  the 


TREATMENT  OF  HEMORRHAGE.        325 

tampon  once  in  operating  on  the  tongue,  and  once  (unneces- 
sarily as  it  turned  out)  in  operating  on  the  palate ; 
but  the  objection  to  it  is,  that  the  pressure  exerted  on  the 
trachea  is  apt  to  produce  great  embarrassment  of  breathing 
and  cougli.  Plugging  the  pharynx  with  a  sponge,  to  which 
a  string  is  attached,  is  a  far  preferable  plan^  and  I  strongly 
advise  that  the  preliminary  tracheotomy,  if  considered  neces- 
sary, should  be  done  a  couple  of  days  beforehand,  so  that 
the  patient's  windpipe  may  have  become  accustomed  to  the 
presence  of  the  tube.  A  much  more  satisfactory  plan,  if  it 
prove  generally  feasible,  is  that  practised  by  Dr.  McEwen, 
of  Glasgow  {British  Medical  Journal,  July  24,  1880) — 
viz.,  to  introduce  a  tracheal  tube  through  the  mouth  for 
the  administration  of  chloroform  during  operations  in  the 
mouth,  the  pharynx  being  plugged  around  the  tube  with 
sponge. 

The  fear  of  haemorrhage  in  cases  of  removal  of  the  upper 
jaw  is  exaggerated,  1  think,  for  there  is  no  large  vessel 
implicated  until  the  last  stage  of  the  proceeding,  when  the 
bone  is  forcibly  displaced ;  and  then,  if  the  operator  is  rapid 
in  his  movements  and  his  assistants  are  prompt,  pressure  can 
be  made  with  a  sponge  thrust  into  the  cavity  quite  sufficient 
to  prevent  blood  flowing  into  the  fauces,  until  the  operator  is 
ready  to  pick  up  the  bleeding  vessel.  I  always  provide 
myself  with  a  small  sponge,  which  I  thrust  into  the 
posterior  nostril  of  the  affected  side  the  moment  the 
larger  sponge  held  by  an  assistant  is  removed.  This  pre- 
vents any  blood  flowing  into  the  pharynx,  and  allows  of  de- 
liberate examination  and  the  arrest  of  bleeding  by  the  ligature 
or  the  cautery. 

As  regards  the  position  of  the  patient  I  always  have  him 
recumbent,  with  the  head  fairly  raised  on  pillows,  and  invari- 
ably employ  chloroform  as  the  anesthetic,  both  because  it  is 
impossible  to  keep  a  patient  under  the  influence  of  ether 
when  air  must  necessarily  be  admitted  very  freely  by  the 
manipulations  of  the  surgeon,  and  because  of  the  danger  of 
ignition  of  the  vapour  of  ether  in  the  patient's  mouth  by 
the  application  of  the  actual  cautery. 


326  OPERATIONS   ON    THE    UPPER   JAW. 

Since  it  is  iiiiadvisable  that  a  patient  about  to  have  a  jaw 
removed  should  take  food  for  four  hours  beforehand,  lest 
sickness  should  be  induced  Ijy  chloroform  or  swallowing 
blood,  I  am  inchned  to  recommend  a  practice,  which  I 
have  lately  followed,  on  the  suggestion  of  Dr.  Prince,  of 
Jacksonville,  Illinois  {St.  Louis  Medical  and  Surgical  Journal, 
Feb.,  1883) — viz.,  to  inject  into  the  colon,  shortly  before  a 
severe  operation,  a  quantity  of  hot  brandy  and  water^  suited 
to  the  age  and  requirements  of  the  patient.  The  ingenious 
rectal  obturator  devised  by  Dr.  Prince,  or  a  very  similar 
invention  of  Mr.  Edward  Lund  {Lancet,  April  7,  1883),  is  by 
no  means  necessary,  for  the  fluid,  if  injected  with  a  fairly 
long  enema  tube  wdiile  the  patient  is  recumbent  in  bed,  has 
little  tendency  to  escape. 


327 


CHAPTEE  XXII. 


NON-MALIGNANT    TUMOURS    OF    THE    LOWER   JAW. 

Fibroma,  Enchondroma,  Osteoma. 

Fibrous  Tumour  is  the  commonest  form  of  growth  in  the 
lower  jaw,  and,  as  pointed  out  by  Paget,  this  may  take  the 
endosteal  or  periosteal    form.       The  formation    of    fibrous 

Fig.  151. 


tumours  between  the  plates  of  the  lower  jaw  has  been 
already  referred  to  under  the  head  of  Inflammation  (p.  98), 
and  originates,  I  believe,  in  the  majority  of  cases  in  some 


328     NON-MALIGNANT   TUMOUKS   OF   LOWER  JAW. 

inflammatory  deposit  due  to  the  irritation  of  decayed  teeth. 
By  the  slow  growth  of  the  tumour  the  jaw  is  expanded,  the 
outer  plate  yielding  more  readily  than  the  inner,  as  is  well 
seen  in  a  preparation  in  University  College  Museum  (fig.  151), 
which  also  shows  a  curious  transportation  of  the  wisdom 
tooth  close  up  to  the  condyle  of  the  jaw  by  the  growth  of 
the  tumour,  being  probably  connected  with  it  in  some  way. 
In  the  College  of  Surgeons'  Museum  (2219)  is  a  good 
specimen  of  endosteal  fibrous  tumour,  which  Sir  Spencer 
Wells  removed  with  the  jaw  from  the  symphysis  to  the 
angle,  in  a  woman  aged  twenty-seven,  whose  condition  at 
the  time  of  the  operation  is  represented  in  fig.  152,  from  a 
photograph  by  the   late  Dr.  Wright.     The  tumour  occupied 

Fig.  152. 


the  left  side  of  the  lower  jaw,  and  had  existed  for  four 
years,  being  connected  with  decayed  teeth,  one  of  which  on 
being  extracted  shortly  before  the  operation  brought  a  small 
portion  of  the  tumour  away  with  it.  Fig.  153,  also  by  Dr. 
Wright,  shows  the  tumour  in  the  recent  state  (see  Patlwlo- 
fjical  Society's  Transactions,  vol.  xii.). 

It  may,  I  think,  be  doubted  whether  a  milder  treatment 
than  that  of  removal  of  the  whole  thickness  of  the  bone 
containing  tumours  of  this  description  might  not  sometimes 


FIBROMA   OF   LOWER  JAW. 


329 


be  adopted  with  advantage.  A  specimen  in  the  Museum 
of  ling's  College  (132-19),  which  is  represented  in  fig.  154, 
admirably  illustrates  this  view.     It  is  a  fibrous  tumour  re- 


FiG.  153. 


moved,  when  I  happened  to  be  present,  by  Sir  William  Fer- 
gusson,  from  a  woman  who  had  undergone  two  previous 
operations.     Having  sawn  the  jaw  partly  through  on  each 


Fig.  154. 


side  of  the  tumour,  the  operator  applied  the  bone-forceps 
to  complete  one  of  the  sections,  when  the  outer  plate  of  the 
jaw  with  the  greater  part  of  the  tumour  came  away,  leaving 


ooO     NON-MALIGNANT   TUMOURS   OF   LOWER   JAW. 

only  a  small  portion  of  it  adhering  to  the  inner  plate.  Owing 
to  the  jaw  being  already  divided,  it  was  considered  better  to 
complete  the  operation  as  originally  intended,  and  the 
patient  made  a  good  recovery.  The  preparation  referred  to 
illustrates  also  the  connection  of  the  teeth  with  fibrous 
tumours,  a  diseased  molar  tooth  being  implanted  in  the 
upper  part  of  the  tumour. 

The  advantage  of  not  breaking  the  line  of  the  lower  jaw 
has  been  already  insisted  upon  in  connection  with  epulis,  and 
the  same  advantage  would  be  gained  by  preserving,  where 
possible,  the  inner  plate  of  the  jaw  in  cases  of  tumour. 

I  have  recently  had  a  patient  under  my  care  who  had  a 
fibrous  tumour  of  the  size  of  a  large  marble,  in  the  lower  jaw, 
in  the  position  of  the  right  molar  tooth.  This  was  imbedded 
between  the  plates  of  the  jaw,  and  had  considerably  ex- 
panded the  bone.  I  succeeded  in  removing  the  growth 
from  within  the  mouth  by  means  of  the  large  forceps  shown 
in  fig.  123,  and  the  patient  made  a  good  recovery.  Sir  J. 
Paget,  in  the  paper  already  referred  to  (p.  322),  gives  two 
cases  in  which  he  successfully  removed  tumours  from  within 
the  lower  jaw,  one,  a  bony  tumour,  and  the  otlier,  and  more 
remarkable  one,  a  cartilaginous  growth  which  was  removed 
by  the  gouge,  and  did  not  reappear. 

A  specimen  of  fibrous  tumour,  presented  to  the  College  of 
Surgeons'  Museum  (2217)  by  Mr.  Bryant,  illustrates  the 
same  point.  The  section  shows  that  the  fibrous  tumour 
is  free  towards  the  alveolar  border  of  the  jaw,  but  enclosed 
in  the  bone  below.  It  is  separated  at  all  parts  from  the 
osseous  tissue  by  a  fibrous  lajer  forming  a  kind  of  capsule, 
and  might  tlierefore  probably  have  been  enucleated  from  its 
cavity  without  any  great  dilliculty. 

A  specimen,  now  in  the  Museum  of  the  College  of  Sur- 
geons (2220),  and  for  which  I  was  indebted  to  Mr.  Buxton 
Shillito,  shows  the  satisfactory  result  of  the  treatment  here 
recommended.  The  case  is  reported,  with  drawings,  in  the 
PatJwlogical  Transactions,  vol.  xvi.,  and  the  tumour  was 
removed  by  Mr.  Shillito  from  near  the  angle  of  the  lower 
jaw  of  a  young  woman  aged  twenty-six,  where  it  had  been 


FIBROMA   OF   LOWER  JAW. 


331 


growing  fifteen  months,  being  of  the  size  of  a  walnut.  It 
was  removed  by  reflecting  a  flap  of  skin  from  its  surface, 
cutting  through  the  thin  shell  of  bone,  and  enucleation. 
It  left  a  perfectly  smooth  cavity  into  which  the  fang  of  the 
second  molar  tooth  projected,  which  doubtless  was  the 
original  cause  of  the  mischief.  The  tumour  was  gritty  on 
section,  and  furnished  an  example  of  calcification,  to  which 
change  fibromata  of  the  lower  jaw  are  liable  no  less  than 
those  of  the  upper  jaw. 

Though  of  slow  growth  under  ordinary  circumstances,  a 
fibrous  tumour  of  the  jaw,  if  irritated  by  the  injudicious 
application  of  useless  remedies  with  the  view  of  producing 
absorption  of  the  growth,  may  assume  enormous  proportions, 
and  destroy  life  by  the  irritation  and  continuous  discharge 
it  gives  rise  to.  A  preparation  in  King's  College  Museum, 
shows  a  fibrous   tumour  of   large  size,  involving   nearly  the 

Fig.  155. 


whole  of  the  left  side  of  the  lower  jaw.  Its  interior  is 
hollowed  out  into  a  large  cavity  with  sloughing  walls,  and 
there  is  a  large  aperture  communicating  with  it  surrounded 
by  healthy  skin.  The  patient's  portrait,  taken  about  six 
weeks  before  her  death,  is  seen  in  fig.  155.  The  case 
was  evidently  one  of  ordinary  fibrous  tumour  depending 
originally  upon   diseased  teeth,  which,  by  dint  of    incisions 


332     NON-MALIGNANT   TUMOUES   OF   LOWER  JAW. 

and  injections  of  iodine  into  the  growth,  followed  by  a  seton 
introduced  through  the  skin,  was  brought  into  such  a  con- 
dition that,  upon  the  receipt  of  a  blow,  it  rapidly  brought 
the  patient  to  her  deathbed. 

A  remarkable  and  unique  feature  in  connection  with 
the  case  of  large  fibrous  tumour  above  referred  to,  is  seen 
in  fig.  156,  which  shows  the  front  of  the  base  of  the 
skull  of  the  patient.  The  long-continued  pressure  of  the 
tumour  of  the  lower  jaw  has  given  rise  to  a  remarkable  con- 
traction  of   the  hard  palate  and   alveolus,  the  teeth  being 

Fig.  156. 


crushed  together  so  as  to  overlap  one  another,  and  at  the 
same  time  an  expansion  of  the  malar  bone  and  zygoma  has 
ensued,  wliich  is  accurately  shown  in  the  drawing. 

A  large  tumour  of  the  same  kind,  weighing  eighteen 
ounces,  which  has  encroached  upon  tlie  condyle  and  coro- 
noid  process,  and  projected  into  the  mouth  as  well  as  on  the 
surface,  is  preserved  in  University  College  Museum  (652), 
and  was  removed  by  Mr.  Listen  in  1846 ;  and  a  similar 
growth,  successfully  removed  by  Prof.  William  Beaumont,  of 
Toronto,  from  a  boy  of  seven,  which  is  considerably  infiltrated 
with  calcareous  matter,  is  in  the  Museum  of  the  College  of 


FIBROMA    OF    LOWER    JAW.  333 

Surgeons  (2218),  and  was  originally  considered  to  be  carti- 
laginous {Medico-Chirurgical  Transactions,  vol.  xxxiii.).  It 
weighed  eight  ounces  avoirdupois,  with  a  long  diameter 
of  3-%  inches,  and  a  short  diameter  of  2-^  inches,  and 
involved  the  whole  of  the  left  side  of  the  bone. 

The  patient,  a  child  aged  seven  years,  was  admitted  into 
the  Toronto  Hospital,  Sept.  17,  1849.  The  tumour,,  on 
his  admission,  extended  upwards  to  the  zygoma  and  malar 
bone,  almost  covering  the  temporo-maxillary  articulation  ; 
it  reached  downwards  to  fully  an  inch  below  the  angle  of 
the  jaw,  extending  inwards  into  the  mouth  as  far  as  the 
mesial  plane ;  backwards  beyond  the  ramus  of  the  jaw,  and 
forwards  to  the  posterior  bicupsid.  It  pushed  the  tongue 
quite  to  the  right  of  the  mesial  plane,  concealed  the  velum, 
and  almost  completely  filled  the  isthmus  faucium ;  the 
molar  teeth  of  the  upper  jaw  were  deeply  imbedded  in  the 
tumour,  which  kept  the  mouth  at  all  times  open,  with  a 
constant  dribbling  of  saliva,  the  upper  and  lower  incisors 
not  meeting  by  fully  half  an  inch.  The  tumour  had  been 
first  observed  three  months  before.  On  Sept.  25,  1849, 
Professor  Beaumont  performed  the  operation  for  its  removal, 
commencing  by  making  a  curved  incision  (the  concavity  up- 
wards), extending  from  the  lobule  of  the  ear  to  the  angle  of 
the  mouth,  dissecting  off  the  integuments  from  the  tumour. 
The  tumour  was  firmly  wedged  in  under  the  malar  bone ; 
the  outer  wall  of  the  jaw  was  cut  vertically  through  with  a 
small  straight  saw ;  the  section  was  then  at  one  stroke  com- 
pleted with  a  strong  bone-forceps ;  the  condyle  was  disarti- 
culated by  being  firmly  grasped  in  a  forceps,  the  joint  being 
opened  by  dividing  the  external  lateral  ligament  and  cap- 
sule. The  patient  did  very  well ;  a  small  salivary  fistula  was 
formed  in  the  cheek,  which  eventually  healed^  and  on  Dec.  1, 
1849,  the  patient  was  quite  w^ell.  The  right  half  of 
the  lower  jaw  was  drawn  a  very  little  towards  the  left  side, 
about  an  eighth  of  an  inch  ;  the  external  cicatrix  was  a 
mere  line. 

Fibrous  tumour  is  most  frequently  developed  in  the  side 
of    the  lower  jaw,  where  the  space  between  the  plates  is 


334     NON-MALIGNANT   TUMOURS   OP   LOWER  JAW. 

larger  than  elsewhere,  and  may  occupy  the  dental  canal,  as 
in  a  case  of  Mr.  Cock's,  in  which  the  dental  nerve  passed 
through  the  tumour,  necessitating  its  removal  in  two  parts 
(Guy's  Hospital  Museum,  1091,  25).  Occasionally,  however, 
fibrous  tumour  invades  the  symphysis,  and  here,  owing  to 
restricted  amount  of  expansion  of  which  the  bone  is  capable, 
absorption  of  the  anterior  surface  takes  place  at  an  early 
date,  and  the  tumour  projects,  involving  also  the  adjacent 
bone.  A  preparation  in  University  College  (655)  shows  the 
symphysis  affected  in  this  way,  which  was  removed,  with  a 
portion  of  healthy  bone  on  each  side,  by  Mr.  Liston.  A 
section  shows  the  structure  very  well,  and  at  the  lower  part 
a  small  cyst  has  been  developed.  In  connection  with  this 
subject,  another  preparation  in  the  same  museum  (654)  is 
deserving  of  notice,  being  a  fibrous  tumour,  of  the  size  of 
an  orange,  connected  with  the  back  of  the  symphysis,  and 
apparently,  therefore,  of  the  periosteal  variety. 

The  periosteal  variety  of  fibrous  tumour  is  not  distin- 
guishable from  epulis  except  by  its  size.  Like  epulis  it  has 
spicula  of  bone  springing  from  the  jaw,  permeating  it  for  a 
short  distance,  and  beyond  them  radiating  lines  may  be  seen 
in  the  fibrous  tissue.  Preparation  2221  in  the  Museum  of 
the  College  of  Surgeons,  which  accompanied  this  essay,  and 
for  which  I  was  indebted  to  Mr.  Lee,  of  the  Salisbury 
Infirmary,  illustrates  this  form  of  disease  very  well,  the 
fibrous  growth  being  closely  connected  with  the  periosteum 
of  the  front  of  the  jaw.  The  disease  may,  however,  almost 
completely  [surround  the  jaw,  as  the  preparation  in  St. 
Bartholomew's  Hospital,  drawn  by  Sir  J.  Paget  in  his 
"  Surgical  Pathology." 

Encliondroma  of  the  loM'er  jaw  is  not  common,  but  is 
found  of  two  forms,  the  endosteal  and  periosteal,  thus 
resembling  fibroma.  The  disease  generally  occurs  early  in 
life,  and  makes  slow  but  steady  progress,  the  periosteal 
variety  acquiring  a  very  large  size.  A  specimen  in  Guy's 
Hospital  Museum  (1019,  15,  and  16)  shows  very  well  the 
relation  of  the  endosteal  variety  to  the  bone,  the  growths 
occupying  the  space  between  the  plates  of  the  jaw,  and  the 


ENCHONDROMA    OF    LOWER   JAW.  335 

teeth  being  imbedded  in  it.  The  specimen  was  removed  by 
Mr.  Key  from  a  woman  aged  twenty-nine,  in  whom  it  had 
been  growing  nine  years,  by  sawing  through  the  bone  on 
each  side  of  the  tumour. 

A  somewhat  similar  case  is  recorded  by  Sir  Astley  Cooper, 
in  his  "  Essay  on  Exostosis,"  and  is  remarkable  both  for  the 
sound  pathological  views  and  strictly  conservative  treatment 
he  therein  advocates.  The  patient  was  nineteen,  and  had 
had  a  growth  in  the  side  of  the  lower  jaw  for  three  years. 
Sir  Astley  exposed  the  tumour  and  gouged  it  away,  exposing 
the  dental  nerve,  and  the  patient  made  a  good  recovery. 
He  remarks  respecting  it  (p.  177),  "  With  regard  to  the 
cause  of  the  disease,  it  was  evidently  the  irritation  of  the 
decayed  tooth,  the  fangs  of  which  projected  into  the  carti- 
lage which  was  effused  within  the  bony  cavity,  and  which, 
instead  of  producing  suppuration  and  ulceration,  as  it  fre- 
quently does,  kept  up  a  degree  of  irritation  that  did  not 
pass  beyond  the  stage  of  adhesive  inflammation,  and  a  cartila- 
ginous deposit  took  place  in  the  first  instance,  to  which  suc- 
ceeded an  ossific  effusion.  As  to  the  treatment  of  this 
disease,  it  consists  in  first  seeking  the  source  of  the  irrita- 
tion and  removing  it  as  soon  as  discovered,  in  order  to  pre- 
vent the  further  progress  of  the  disease  ;  and,  indeed,  it  may 
be  probable  that  the  removal  of  the  source  of  irritation 
might  sometimes,  even  when  the  disease  has  advanced  to  a 
considerable  extent,  succeed  in  producing  a  cure,  and  there- 
fore it  is  desirable  to  wait  the  event  before  any  further  opera- 
tion is  undertaken.  Should  this,  however,  prove  insuffi- 
cient, it  will  be  necessary  that  the  external  shell  of  the  bone 
be  removed  by  means  of  a  saw,  and  that  the  cartilage  which 
it  contains  be  dislodged  by  an  elevator.  If  the  integuments 
be  carefully  preserved,  little  deformity  follows ;  and  thus, 
by  a  simple  operation,  destruction  otherwise  inevitable  is 
prevented."  Sir  James  Paget  has  recorded  {Mcclico-Chirm'' 
gical  Transactions,  1871),  a  very  similar  case  of  cartila- 
ginous tumour  in  the  lower  jaw  of  a  lady  forty-five  years 
old.  It  had  been  growing  during  two  or  three  years,  extended 
along  the  space  between  the  first  bicuspid  and  last   molar 


336     NON-MALIGNANT   TUMOURS   OP   LOWER   JAW. 

teetli,  was  deep  set  in  the  jaw,  expanding  both  the  walls, 
and  rising  to  almost  the  level  of  the  molar  teeth.  He 
gouged  it  out,  leaving  the  base  of  the  jaw  untouched,  and 
not  cutting  any  part  of  the  cheek  or  lip.  The  patient  had 
no  return  of  the  disease. 

The  periosteal  form  of  enchondroma  springs  from  the 
membrane  covering  any  portion  of  the  bone,  but  most  fre- 
quently affects  the  body.  It  grows  to  an  enormous  size, 
and  may  cause  death  either  by  interfering  with  respiration, 
as  in  Sir  Astley  Cooper's  case,  or  with  deglutition,  as  in  the 
case  from  which  the  preparation  in  the  College  of  Surgeons 
was  taken. 

Sir  Astley's  patient  was  a  girl  of  thirteen,  in  whom  the 
tumour  had  made  its  appearance  near  the  cliin  a  year  before 
she  came  under  that  surgeon's  notice.  The  tumour  increased 
until  it  measured  five  inches  and  a  half  from  side  to  side,  and 
four  inches  from  the  incisor  teeth  to  its  anterior  projecting 
part.  The  circumference  of  the  swelling  was  sixteen  inches. 
The  tongue  was  thrust  back  into  the  throat  and  to  the  right 
side,  where  it  rested  in  a  hollow  between  the  angle  of  the  jaw 
and  the  tumour.  The  epiglottis  was  bent  down  upon  the 
rima  glottidis  so  as  to  produce  great  difficulty  in  swallowing 
and  breathing.  The  mental  foramen  was  large  enough  to 
admit  the  little  finger,  and,  owing  to  the  elongation  of  the 
bone,  was  directed  backwards.  The  preparation  is  preserved 
in  the  Museum  of  St.  Thomas's  Hospital  (C.  201),  and  a 
section,  whicli  has  been  macerated,  shows  very  well  the  ossific 
spicula  from  the  surface  of  the  bone  projecting  into  the  mass. 

In  the  Museum  of  the  College  of  Surgeons  is  a  still  more 
remarkable  specimen  of  the  same  disease  (2215),  the  tumour 
measuring  six  inches  in  depth  and  about  two  feet  in  cir- 
cumference, and  involving  the  whole  of  the  lower  jaw  except 
the  right  ramus  and  angle.  The  patient,  when  thirty-two, 
had  a  small  hard  tumour  on  the  right  side  of  the  lower  jaw^, 
just  below  the  situation  of  the  first  molar  tooth,  which  had 
decayed.  This  gradually  increased,  and  ultimately  proved 
fatal  at  the  end  of  eight  years,  by  inducing  inability  to 
swallow. 


ENCHONDEOMA   OF   LOWER   JAW.  337 

A  specimen  of  enchondroma,  weighing  three  and  a-half 
pounds  (German),  removed  by  disarticulation  by  Chelius, 
is  preserved  in  the  Heidelberg  Museum,  and  is  figured  by 
Otto  Weber  {o}-).  cit.). 

A  remarkable  case  of  enchondroma  of  the  lower  jaw  has 
been  recorded  by  Mr.  Lawson  (Pathological  Society  s  Trans- 
actions xxxiv.),  in  which  there  were  ten  operations  for  as 
many  recurrences  during  eighteen  years.  The  report  of  a 
committee  on  some  of  the  more  recent  recurrences  goes  to 
show,  however,  that  these  are  more  of  the  nature  of  spindle- 
celled  sarcoma. 

The  history  of  the  case  goes  back  to  1865,  when  the 
patient  came  under  Sir  William  Fergusson's  care  on  account 
of  a  large  tumour,  bulging  below  the  jaw,  and  pushing  into 
the  mouth.  He  then  removed  the  tumour,  and  at  the  same 
time  took  away  five  teeth  from  the  lower  maxilla,  which 
appear  to  have  been  dis^^laced  by  it.  She  made  an  excel- 
lent recovery,  and  for  a  time  remained  well,  but  the  tumour 
recurred,  and  after  two  or  three  years  was  again  removed  by 
Sir  William  Fergusson.  Unfortunately  the  patient  had 
kept  no  account  of  the  dates  of  the  different  operations  she 
had  undergone.  She  was  only  able  to  say  that  she  was 
operated  on  twice  between  the  years  1865  and  1872, 
and  three  times  between  1872  and  1876 ;  the  last 
operation  being  in  ISTovember,  1876,  when  Sir  William  ap- 
parently succeeded  in  getting  away  the  whole  of  the 
growth. 

On  December  26,  1877,  the  patient,  aged  fifty-seven,  a 
stout  healthy-looking  woman,  was  admitted  into  the  Esta- 
blishment for  Invalid  Ladies,  under  Mr.  Lawson,  for 
the  purpose  of  having  the  tumour  again  removed.  Since 
the  last  operation  the  tumour  had  recurred,  and,  as  she 
could  not  have  the  benefit  of  Sir  William  Fergusson's 
assistance,  she  had  allowed  the  growth  to  remain  until  it 
had  attained  such  dimensions  that  she  was  compelled  to  seek 
relief. 

On  admission,  the  tumour  presented  the  external  appear- 
ance shown  in  the  woodcut  (fig.  157).     It  extended  upwards 

z 


338      NON-MALiaNANT   TUMOURS   OF   LOWER   JAW. 

to  the  level  of  the  lower  part  of  the  ear,  downwards  in  the 
neck  to  within  two  fingers'-breadth  of  the  clavicle,  and  for- 
wards it  was  bulging  close  up  to  the  nose.  Looking  within 
the  mouth,  the  tumour  was  seen  to  occupy  the  greater  por- 
tion of  that  cavity ;  and  it  extended  across  the  pharynx 
against  which  and  the  soft  palate  it  pressed.     The  mouth 

Fig.  157. 


could  be  closed,  and  she  could  take  food  without  much  diffi- 
culty, but  her  breathing  was  at  times  troublesome,  and 
especially  at  night. 

On  Jan.  7,  1878,  Mr.  Lawson  removed  the  tumour  with 
the  portion  of  the  lower  jaw  from  the  inner  surface  of  which 
it  grew  (fig.  158),  and  the  patient  rapidly  recovered. 

The  tumour  weighed  close  upon  eighteen  ounces.  It  was 
of  a  firm  consistence,  but  easily  cut  with  the  knife.  It  was 
intimately  connected  with  the  periosteum  on  the  inner  side 
of  the  lower  jaw,  from  wliich  it  apparently  sprang.     A  por- 


ENCHONDEOMA   OF   LOWER   JAW.  339 

tion  of  the  tumour  was  given,  immediately  after  its  removal, 
to  Dr.  Thin,  who  supplied  the  following  report  of  his 
microscopical  examination  : — "  I  examined  microscopically 
the  portion  of  the  tumour  kindly  given  me  by  Mr.  Lawson, 
and  I  believe  the  growth  to  be  a  chondrome  of  the  class 

Fig.  158. 


named  by  Cornil  and  Eanvier  cJwndromes  hyalins  lohides.  It 
has  the  peculiarity  that  the  cartilaginous  tissue  is  of  a  very 
low  type,  so  much  so  that  the  determination  of  the  exact 
nature  of  the  growth  was  a  matter  of  some  difficulty.  Suc- 
cessful preparations,  however,  show  that,  except  in  the 
degree  of  development  of  the  cartilaginous  substance  proper, 
the  structure  is  identical  with  that  described  by  pathologists 
as  characteristic  of  these  tumours." 

Dr.  Coupland,  the  lecturer  on  Pathology  at  the  Middlesex 
Hospital,  examined  the  specimen  of  the  growth  prepared  by 
Dr.  Thin,  and  concurred  in  the  report. 

Since  the  operation  in  1878  there  have  been  five  opera- 
tions for  extensive  recurrence  of  the  disease,  and  on  each 
occasion  similar  masses  of  cartilage  were  removed.  The 
recurrences  have  been  in  the  neck  and  in  the  temporo- 
maxillary  region,  extending  from  the  glenoid  fossa  of  the 
temporal  bone  towards  the  base  of  the  skull,  and  in  the 

Z  2 


340      NON- MALIGNANT   TUMOURS  OF   LOWER  JAW. 

cheek,  between  the  mucous  membrane  and  the  external 
integument.  At  each  operation  the  tumour  was  found  to  be 
composed  of  large  isolated  masses  of  cartilage,  varying  in 
size  from  that  of  the  closed  fist  to  a  small  nut,  packed 
tightly  together,  and  each  portion  enclosed  in  a  distinct 
cajDsule,  from  which  it  could  with  little  difficulty  be  enu- 
cleated. The  masses  of  cartilage  were  of  sufficient  density 
to  push  before  them  in  their  growth  all  important  structures 
with  which  they  were  in  contact.  The  patient  is  still 
living. 

Osteoma  affects  the  lower  jaw  in  two  forms — the  can- 
cellated and  the  ivory  exostosis.  The  former  is  no  doubt  in 
many  cases  the  result  of  ossification  of  enchondroma,  as 
for  instance,  a  specimen  (C.  203)  preserved  in  St.  Thomas's 
Museum,  which  is  of  a  spongy  texture,  and  which  is  stated 
by  Sir  Astley  Cooper  to  have  been  removed  by  Mr.  Cline. 
Occasionally,  however,  a  conversion  of  the  whole  thickness 
of  bone  into  a  lobulated  mass  of  spongy  bone  is  met  with, 
of  which  an  excellent  example  is  preserved  in  St.  George's 
Hospital  Museum  (II.  185).  In  this  case  the  tumour, 
which  was  of  the  size  of  the  fist,  had  been  growing  for  five 
years,  and  had  been  on  one  occasion  partially  removed.  Mr. 
Tatum  successfully  removed  the  entire  portion  of  jaw  affected. 
A  case  in  which,  a  circumscribed  bony  tumour,  measuring 
from  two-thirds  to  three-fourths  of  an  inch  in  diameter,  and 
composed  of  hard,  finely  cancellous  bone,  was  lodged  in  the 
interior  of  the  angle  of  the  jaw,  is  given  by  Sir  J.  Paget  in 
the  Medico- Chirurgical  Transactions,  vol.  liv. 

Ivory  exostosis  appears  to  affect  by  preference  the  angle 
of  the  jaw.  Of  this  a  good  specimen  is  preserved  in  St. 
George's  Hospital  (II.  191);  and  0.  Weber  figures  a  section 
of  a  large  ivory  exostosis  in  the  same  region  removed  by 
Chelius.  The  best  example  of  the  kind,  however,  is  in  the 
College  of  SurgeoDS  (2212),  having  been  presented  by  Mr. 
J.  F.  South.  The  preparation  (post-mortem)  shows  part  of 
the  right  side  of  the  lower  jaw,  with  sections  of  a  large  bony 
tumour  at  its  angle.  The  angle  of  the  jaw  rests  in  a  deep 
groove  on  the  middle  of  the  upper  surface  of  the  tumour, 


OSSEOUS   TUMOURS. 


341 


and  in  some  situations  their  respective  substances  are  con- 
tinuous. The  tumour  projects  both  below  and  on  each  side 
of  the  jaw,  is  of  irregular  shape,  measures  nearly  three 
inches  in  its  chief  diameter,  and  is  deeply  nodulated.  It  is 
composed  throughout  of  bone,  uniform  in  texture,  and  as 
hard  and  heavy  as  ivory  (fig,  159). 

In  the  Museum  of  St.  Bartholomew's  Hospital  is  the 
lower  jaw  of  a  young  person  (I.  3257)  with  two  symmetrical 
eburnated  exostoses  springing  from  the  inner  surface  of  the 
alveolar  portion  of  the  bone  on  either  side  of  the  symphysis, 
corresponding  in  position  to  the  bicuspid  and  first  molar 


Fig.  159. 


teeth.  The  markings  and  slight  lobulations  of  the  bony 
outgrowths  are  more  or  less  symmetrical.  The  rami  of  the 
jaw  are  unusually  widely  separated. 

In  May,  1870, 1  removed  an  ivory  exostosis  from  a  young 
woman  aged  thirty-two,  a  patient  of  Mr.  Ceely,  of  Aylesbury, 
whose  portrait  is  given  in  fig.  160.  There  had  been  a  pain- 
less enlargement  of  the  left  side  of  the  lower  jaw  for  five 
years,  and  there  was  also  a  smaller  enlargement  of  the  right 
side.  A  small  exostosis  also  existed  on  the  left  pubes.  I 
made  an  incision  behind  the  jaw  and  sawed  off  the  growth 


342      NON-MALIGNANT   TUMOURS    OF    LOWER   JAW. 

level  to  the  boue,  removing  a  dense  ivory  growth  measuring 
two  inches  in  length  by  one  inch  in  width,  and  three-eighths 
of  an  inch  thick  in  the  centre  (University  College  Museum 
635).  The  exterior  of  the  growth  presented  a  finely  reticu- 
lated appearance,  and  at  the  upper  part  was  a  small  depres- 
sion filled  with  cartilage  in  the  recent  state.  Two  years 
after  the  operation  I  was  informed  by  Mr.  Ceely  that  there 
had  been  no  reappearance  of  the  growth,  and  that  the  other 

Fig.  160. 


exostosis  remained  in  statu  quo,  and   four  years  later  I  saw 
the  patient,  who  continued  quite  well. 

When  the  exostosis  forms  a  distinct  and  circumscribed 
growth,  whether  it  be  of  the  cancellous  or  ivory  character, 
it  should  be  sawn  off  the  bone  at  the  level  of  the  healthy 
surface,  and  will  in  all  probability  not  recur.  When,  how- 
ever, the  whole  thickness  of  the  bone  is  involved,  as  in  Mr. 
Tatum's  or  Mr.  South's  case,  it  will  be  necessary  to  remove 
a  portion  of  the  bone.  Should  the  tumour  be  imbedded 
between  the  plates  of  the  jaw,  it  should  be  enucleated  if 
possible  without   any  external  incision,  as  in  Sir  J.  Paget's 


OSSEOUS  TUMOURS.  343 

case  given  above.  A  remarkable  case  of  exostosis  of  the 
ramus  of  the  jaw,  reaching  to  the  styloid  process,  has  been 
recorded  by  Mr.  Syme,  in  his  "  Contributions  to  the  Patho- 
logy and  Practice  of  Surgery,"  in  wliich  he  removed  the 
ramus  of  the  jaw,  with  the  growth,  by  an  external  incision, 
without  opening  the  cavity  of  the  mouth. 


344 


CHAPTEE   XXIII. 

SARCOMATOUS    TUMOURS    OF    THE    LOWER   JAW. 

SjpindU'Celled  Sarcoma,  Myeloid  Sarcoma,  Ghondro-Sarcoma, 
Ossifying  Sarcoma. 

Spindle- celled  sarcoma.  This,  the  old-fashioned  osteosar- 
coma, frequently  attacks  the  lower  jaw,  and  may  prove 
fatal,  by  obstruction  either  to  respiration  or  deglutition,  if 
allowed  to  grow  unchecked  for  many  years.  Some  of  the 
earliest  removals  of  portions  of  the  lower  jaw  were  for 
growths  of  this  description  which  had  attained  a  large 
size,  and  the  names  of  Crampton,  Cusack,  and  Syme  are 
connected  with  these  operations.  The  Museum  of  the 
College  of  Surgeons  of  Ireland  is  especially  rich  in  tumours 
of  this  class,  and  possesses  also  a  cast  of  the  head  of  a 
patient  who  died  with  a  large  tumour  of  the  lower  jaw, 
which  has  been  injected  and  divided.  The  following  is  the 
description  of  this  preparation  (I.  a.  361),  kindly  extracted 
for  me  by  Dr.  Barker,  the  Curator  : — "  A  singularly  beauti- 
ful preparation  of  the  osteo-sarcoma  of  the  lower  jaw,  of 
which  the  preceding  cast  gives  an  outline.  The  patient 
was  a  middle-aged  woman.  The  disease  commenced  as  a 
fungus  in  the  alveoli  of  the  front  teeth.  This  fungus  was 
removed  by  operation  at  an  early  period,  but  speedily  grew 
again,  and  in  the  course  of  about  two  years  had  acquired 
its  size,  which  is  equal  to  that  of  an  infant's  head,  without 
bursting  at  any  part.  It  was  firm,  but  elastic  to  the  feel, 
and  inconvenienced  the  pajtient  more  by  its  bulk  than  by 
its  malignancy.  The  woman,  who  was  naturally  of  a  deli- 
cate frame,  gradually  sank  from  exhaustion.  No  preparation 
could    exhibit    more  satisfactorily  the    circumscribed  local 


SPINDLE-CELLED   SARCOMA.  345 

nature  of  this  affection  than  that  here  shown.  It  is  globular, 
four  inches  in  diameter,  and  enveloped  in  an  osseous  wall 
which  has  connection,  exclusively,  with  the  front  central 
portion  of  the  lower  jaw,  and  which  completely  insulates  the 
disease.  The  maxillary  bone  is  perfectly  sound  beyond  the 
points  of  adhesion  of"  the  tumour.  The  centre  of  the  tumour 
is  divided  by  bony  partitions  into  several  chambers,  the 
surfaces  of  which  are  lined  by  a  pulpy  vascular  membrane, 
which  has  received  injection  in  great  profusion.  The  con- 
tents of  these  chambers  were  various — some  gelatinous,  some 
bloody,  and  some  of  a  gTistly  nature,  interspersed  with  bony 
stalactites.  Plate  11,  in  the  fourth  volume  of  the  DuUin 
Eospitcd  Reports,  was  taken  from  this  preparation. — Professor 
Wilmot." 

The  central  portion  of  this  tumour  is  of  such  a  distinctly 
cystic  character  that  modern  pathologists  would  probably 
have  classed  the  disease  among  the  cystic  sarcomata,  but  I 
prefer  to  leave  it  in  the  place  assigned  to  it  by  the  Irish 
pathologists. 

In  the  same  fine  museum  are  the  historically  interesting 
tumours  removed  by  Sir  Philip  Crampton  and  Mr.  Cusack, 
in  1824,  the  details  of  which  cases  wiU  be  found  in  the 
valuable  papers  by  those  two  gentlemen,  in  the  fourth 
volume  of  the  Diiblin  Hospital  Reports  (1827).  Sir  Philip 
Crampton  was  the  first  to  insist  upon  the  non-malignancy  of 
this  form  of  osteo-sarcoma,  and  to  distinguish  it  from  the  me- 
dullary form — up  to  that  time  confounded  with  it.  His  de- 
scription of  the  whole  course  of  the  disease,  as  witnessed  in 
the  jaw,  is  so  perfect  that  I  cannot  do  better  than  reproduce 
it : — "  The  first  indication  of  tliis  formidable  disease  is  the  ap- 
pearance of  merely  a  small  swelling  or  projection  of  the 
gum,  between  two  of  the  teeth.  The  teeth,  however,  soon 
become  loose  and  dislocated,  being  forced  inwards  upon  the 
tongue,  or  outwards  against  the  cheek  ;  as  the  tumour  en- 
larges it  assumes  a  tuberculated  appearance,  the  tubercules 
varying  in  colour  from  a  light  pink  to  a  deep  purple  ;  they 
are  firm  in  structure,  perfectly  indolent,  and  do  not  readily 
bleed  even  when  roughly  handled.     As  the  morbid  growth 


346  SARCOMA    OF    THE    LOWER   JAW. 

extends  in  all  directions,  the  month  is  soon  filled  by  the 
tumour,  the  lower  jaw  is  forced  downwards  upon  the  fore 
part  of  the  neck,  the  tongue  is  pushed  backwards  into  the 
pharynx,  the  mouth  is  carried  to  the  side  of  the  face  opposite 
to  the  tumour,  and  before  the  patient  sinks  under  his  suf- 
ferings, a  tumour  is  sometimes  formed  which  nearly  equals 
the  bulk  of  the  head  itself.  It  is  gratifying,  however,  to  be 
able  to  state  that  even  under  such  deplorable  circumstances 
life  has  been  preserved,  and  the  hideous  deformity  removed  by 
an  operation  which  must  be  considered  as  one  of  the  boldest 
and  most  successful  of  which  modern  surgery  has  to  boast. 
But  it  is  from  the  mternal  stnidure  of  osteo-sarcomatous 
tumours,  as  developed  in  the  course  of  operations  under- 
taken for  their  removal,  or  by  dissection  after  death,  that 
the  true  and  distinctive  characters  of  these  affections  are  to 
be  traced.  In  the  benign  form  of  osteo-sarcoma,  the  local 
and,  I  might  almost  say,  the  encysted  character  of  the  dis- 
ease is  evinced  by  the  distinct  line  which  separates  the 
morbid  growth  from  the  soft  parts  with  which  it  is  in  con- 
tact. It  becomes  apparent  that  as  the  tumour  has  enlarged,  it 
has  pushed  the  soft  parts  before  it,  or  insinuated  itself  into 
their  interstices,  and  that,  so  far  from  becoming  incorporated 
with  the  surrounding  structures,  and  assimilating  them  to  its 
own  nature  (as  invariably  happens  in  tlie  advanced  stage  of 
malignant  tumours),  it  has  formed  attachments  so  slight, 
that  when  the  portion  of  bone  from  whence  the  tumour 
springs  is  detached,  the  whole  morbid  growth  may  be  (as  it 
were)  drawn  out  from  the  surrounding  parts  almost  without 
the  aid  of  the  knife.  The  interior  of  the  tumour  presents 
a  great  variety  of  structure,  but  I  should  say,  in  general,  that 
the  cartilaginous  character  which  the  tumour  exhibits  in  its 
origin  prevails  to  the  last.  In  the  early  stages  of  the  dis- 
ease the  tumour  consists  of  a  dense  elastic  substance, 
resembling  fibro-cartilaginous  structure,  but  the  resemblance 
is  more  in  colour  than  in  consistency,  for  it  is  not  nearly  so 
hard,  and  is  granular  rather  than  fibrous,  so  that  it  '  breaks 
short.'  On  cutting  into  the  tumour  the  edge  of  the  knife 
grates  against  spicnla,  or  small  grains  of  earthy  matter,  with 


SPINDLE-CEI.LED    SARCOMA. 


347 


which  its  substance  is  beset.  If  the  tumour  acquires  any 
considerable  size,  it  is  usually  found  to  contain  cavities  filled 
with  fluids  differing  in  colour  and  consistency,  but  in  general 
the  fluid  is  thickish,  inodorous,  and  of  the  colour  of  chocolate. 
Sometimes  the  growth  of  the  tumour,  or  the  secretion  of 
fluid  within  its  substance,  is  so  slow  that  the  deposition  of 
bony  matter  keeping  pace  with  the  absorption,  the  bone  be- 
comes expanded  into  a  large  and  thick  bony  case,  in  which 
the  tumour  is  completely  enclosed.     There  is  a  beautiful 


Fig.  161. 


Fig.  162. 


preparation  of  this  form  of  the  disease  in  the  Museum  of 
the  Eoyal  College  of  Surgeons.  But  in  general  the  walls 
of  the  cavity  consist  of  cartilaginous  structure  mixed  with 
bone,  the  bone  bearing  but  a  small  proportion  to  the 
cartilage.  The  extent  to  which  this  description  of  tumour 
may  increase  without  materially  affecting  the  general  health, 
is  one  of  the  most  extraordinary  circumstances  connected 
with  its  history"  (p.  541). 

The  "  cartilaginous"  appearance  here  referred  to,  relates 
only  to  the  naked-eye  appearance  of  the  structure,  which  is 
characteristically  said  to  "  break  short."     Microscopic  exami- 


348  SARCOMA    OF  THE  LOWER   JAW. 

nation,  as  I  have  had  the  opportunity  of  observing  in  a 
large  tumour  of  the  kind,  shows  a  dimly  granular  stroma, 
closely  resembling  the  matrix  of  cartilage,  but  containing  no 
true  cartilage -cells.  Though  parts  of  the  tumour  may  show 
structure  of  this  kind,  the  greater  part  is  usually  of  a  dis- 
tinctly' spindle-cell  character. 

In  1828  Mr.  Syme  removed  a  very  large  tumour  of  this 
description  (probably  the  largest  which  has  ever  been  re- 
moved), weighing  4^1bs.,  which,  no  doubt,  for  the  reason 
given  above,  he  refers  to  in  a  lecture  published  in  the 
Lancet,  Feb.  3,  1855,  as  a  fibro-cartilaginous  tumour.  The 
patient  made  a  good  recovery,  and  the  accompanying  illus- 
trations, figs.  161  and  162,  for  which  I  was  indebted  to 
Mr.  Syme,  show  his  condition  before  and  some  years  after 
the  operation,  which  was  one  of  the  earliest  of  the  kind  in 
this  country. 

The  spindle-celled  sarcoma  will,  if  its  surface  be  irritated 
by  caustics,  &c.,  throw  out  fungus  masses,  which  bleed,  and 
may  be  mistaken  for  malignant  fungus.  Mr.  Cusack  {loc. 
cit.)  gives  an  example  of  this  result  occurring  from  slough- 
ing of  the  skin  of  the  face,  due  to  over-distension  by  the 
tumour,  and  I  had  under  my  care  some  years  back  an 
extraordinary  instance  of  the  kind,  where  quack  applica- 
tions had  produced  similar  results.  Occasional  haemorrhage 
from  such  surfaces  led  to  these  cases  being  massed  to- 
gether with  cancer  as  examples  of  fungus  hcematodes,  and 
doubtless  Sir  William  Fergusson's  observation  is  correct, 
that  the  rarity  of  fungus  h?ematodes  in  the  present  day,  is 
due  to  the  early  treatment  to  which  cases  of  this  kind  are 
submitted. 

The  portrait  of  the  patient  formerly  under  my  own  care, 
to  whom  I  have  alluded,  is  shown  in  fig.  163,  taken  from 
a  photograph,  and  his  case  will  be  found  in  detail  in  the 
Appendix  (Case  XII.).  The  enormous  size  of  the  tu- 
mour can  be  best  appreciated  by  the  figure,  the  measure- 
ments being  as  follows  : — From  the  lobule  of  one  ear  round 
the  chin  to  the  lobule  of  the  other  was  19-^  inches ;  from 
the  edge  of  the  lower  lip  over  the  chin  to  the  pomum  Adami 


SPINDLE-CELLED    SARCOMA. 


349 


13  inches ;  and  the  width  of  the  face  was  14  inches.  The 
circumference  of  the  lips  was  9 J  inclies.  The  patient  was 
only  thirty-two,  and  the  disease  appeared  to  have  commenced 


Fig.  163. 


eleven  years  before,  in  a  small  swelling  below  the  right 
canine  tooth,  but  the  whole  of  the  large  growth  had  taken 
place  within  four  or  five  years.  The  fungous  protrusions 
were,  as  has  been  mentioned,  the  result  of  the  application  of 
quack  remedies.  The  patient,  when  he  came  under  my 
notice,  was  in  a  miserable  condition,  being  nearly  starved, 
owing  to  the  tumour  forming  a  projecting  mass  within  the 
mouth,  which  completely  concealed  the  tongue,  and  was 
nearly  in  contact  with  the  palate.  I  succeeded  in  removing 
the  tumour  by  sawing  in  front  of  the  left  angle  and  dis- 
articulating on  the  right  side,  with  very  little  loss  of  blood, 
but  the  patient  died  exhausted  on  the  sixth  day.  The 
tumour  weighed  41b,  6oz.,  and  is  now  in  the  Museum  of  the 


350 


SA.RCOMA   OF   THE   LOWER   JAW. 


College  of  Surgeons  (2234).  Its  appearance  (reduced  to 
about  one-third)  is  shown  in  fig.  164.  A  section  has  been 
made  to  show  its  structure,  which  is  precisely  that  described 
by  Sir  P.  Crampton,  the  mass  being  made  up  of  fibro-cellular 
tissue  of  different  degrees  of  density,  with  here  and  there 
small  nodules  of  bone,  and  a   few  small  cysts  interspersed 


Fig.  164. 


through  its  structure.  The  tumour  evidently  commenced  in 
the  interior  of  the  jaw,  the  outer  plate  being  considerably 
expanded  and  destroyed  in  parts,  while  the  inner  remains 
perfect,  and  can  be  seen  in  the  condition  in  which  it  was 
left  at  the  operation.     The  mass  in  growing  has  carried  up 


SPINDLE-CELLED    SARCOMA.  351 

the  teeth  with  it,  and  they  project  from  it  at  irregular 
intervals,  a  considerable  portion  of  the  growth,  and  probably 
the  most  recently  formed  part,  being  posterior  to  them, 
occupying  as  it  did  the  mouth  and  lying  among  the  muscles 
beneath  the  tongue.  The  fungoid  masses  are  covered  with 
granulations,  but  otherwise  differ  in  no  way  from  the  rest  of 
the  growth. 

I  was  indebted  to  the  late  Mr.  A.  Bruce  for  the  following 
elaborate  report  upon  the  structure  of  this  tumour  : — "  The 
tumour  consists  of  a  lobulated  mass  of  soft  but  elastic  con- 
sistence, resembling  in  parts  a  recent  decolorized  fibrinous 
coagulum.  It  is  for  the  most  part  of  a  pale  straw-colour, 
with  here  and  there  patches  of  a  flesh-tint,  and  mottled  in 
spots  with  deep  crimson.  In  front  is  a  prominent  fungating 
mass,  which  had  penetrated  through  the  skin  at  the  time  of 
the  operation.  The  structure  consists  of  a  fine  fibrinous 
stroma,  varying  in  different  parts  in  its  degree  of  fibrillation; 
in  some  portions  there  are  very  distinct  fibres,  in  others 
only  imperfect  ones^  as  is  frequently  seen  in  rapidly  growing 
parts,  whilst  in  others  again  the  stroma  is  dimly  granular, 
and  closely  resembles  the  matrix  of  cartilage,  but  differs 
from  it  in  its  softness  ;  this  latter  character  is  limited  to  the 
parts  in  the  interior  in  immediate  connection  with  the  bone. 
Imbedded  in  this  stroma  are  numerous  cells,  lying  for  the 
most  part  with  their  axes  parallel  to  one  another,  but  in 
many  places  without  any  apparent  uniformity  in  this  par- 
ticular. The  cells  are  small  in  size,  at  first  sight  more 
resembling  elongated  nuclei,  but  in  all  cases  a  cell-wall  may 
be  distinctly  traced  when  a  sufficiently  high  power  is  em- 
ployed. The  majority  are  elongated  fusiform  or  fibre  cells, 
with  a  considerable  proportion,  however,  of  oval,  rounded,  or 
even  polygonal  cells.  Their  size  varies  from  to  -a-roo-to-g^-o  inch 
in  diameter.  The  nuclei  are  proportionately  large  and  pro- 
minent, and  contain  one  or  two  very  distinct  glistening 
nucleoli.  The  cell  contents,  when  any  exist,  are  granular. 
Some  of  the  rounded  and  polygonal  cells  closely  resemble 
those  found  in  malignant  growths,  especially  in  the  irregu- 
larity of  their  arrangement  and  their  large  eccentric  nucleus  ; 


352  SARCOMA    OF   THE    LOWER   JAW. 

one  cannot,  however,  lay  much  stress  upon  these  characters 
in  the  present  case,  considering  the  small  proportion  which 
these  cells  bear  to  the  whole  mass  of  the  tumour.  Frao;- 
ments  of  bone  and  of  calcareous'  matter  are  found  scattered 
throughout  the  tumour,  and  appear  to  be  in  part  derived 
from  tlie  jaw  itself,  and  in  part  to  be  a  new  development. 
The  general  structure  of  the  tumour  is  that  usually  described 
under  the  head  of  osteo-sarcoma,  and  it  belongs  evidently  to 
the  group  of  simple  fibro-plastic  tumours,  but  differs  from 
the  myeloid  fibro-plastics  in  tlie  equal  proportion  existing 
between  the  cellular  and  fibrous  elements." 

Mr.  Eve  has  recently  re-examined  this  tumour,  and  has 
found  scattered  throughout  it  masses  and  cylinders  of  epithe- 
lial cells,  resembling  the  epithelial  elements  of  the  cystic 
tumours  of  the  lower  jaw  already  described  (p.  196).  They 
were  composed  of  large  irregularly  shaped  or  branched  masses, 
and  of  small  columns  composed  of  round  epithelial  cells, 
with  a  layer  of  peripheral  elongated  cells.  (For  drawing, 
see  Lecture  by  Mr.  Eve,  British  Medical  Journal,  Jan.  6, 
1883.) 

Under  the  head  of  Spindle- celled  Sarcoma  must  be 
included  the  following  two  cases,  which  have  hitherto  been 
classed  as  "  recurrent  fibroid." 

The  first  occurred  in  the  Westminster  Hospital,  under 
the  care  of  Mr.  Holt,  in  1858,  in  a  young  woman  aged 
eighteen,  who  had  a  sort  fungoid  mass  covering  the  molar 
teeth  of  the  right  side  of  the  lower  jaw,  of  ten  weeks' 
duration.  It  apparently  sprang  from  the  angle  of  the 
jaw  or  the  base  of  the  ascending  ramus,  and  had  pushed 
the  mucous  covering  before  it.  The  molar  teeth  were 
firmly  fixed  in  their  sockets ;  the  wisdom  tooth  was  covered 
with  gum.  The  rapid  growth  of  the  fungus,  and  the 
absence  of  any  material  pain,  led  to  the  conclusion  that  it 
was  probably  a  form  of  epulis  of  a  malignant  type.  Mr. 
Holt  therefore  thought  it  advisable  to  remove  the  whole 
mass,  and  examine  the  bone  prior  to  removal  of  the  jaw 
itself.  This  beiug  done,  its  attachments  were  found  to  be 
connected  with  the  posterior  part  of  the  body  and  anterior 


SPINDLE-CELLED  SARCOMA.  353 

part  of  the  ascending  ramus,  the  bone  being  liard  and  of  its 
ordinary  density.  Mr.  Holt  did  not  feel  warranted  in  doing 
that  which  he  was  prepared  to  do  — namely,  remove  the  bone 
at  its  articulation  at  this  time — but  preferred  removing  with 
the  cutting  pliers  all  tlie  bone  to  which  the  growth  had  been 
attached.  Mr.  Clendon  having  then  extracted  the  molars 
and  wisdom  tooth,  Mr.  Holt  cut  through  half  the  thickness 
of  the  jaw  corresponding  to  those  teeth,  and,  going  further 
back,  included  the  coronoid  process,  with  more  than  half  of 
the  sigmoid  notch.  The  disease  was  found  to  be  intimately 
connected  with  the  periosteum,  which  readily  peeled  off, 
leaving  the  bone  somewhat  roughened.  (See  Lancet,  Jan. 
28,  1858.) 

The  disease  reappeared  in  a  few  weeks,  when  Mr.  Holt 
was  compelled  to  remove  it  again,  including  this  time  the 
remaining  part  of  the  ramus  of  the  jaw.  The  disease  now 
was  not  confined  to  the  covering  of  the  bone,  but  extended 
into  the  pharynx,  and  was  evidently  attached  to  the  mucous 
lining  of  the  whole  of  one  side  of  the  mouth. 

The  poor  girl  left  the  hospital  and  went  to  Eeading,  and 
died  on  the  3rd  of  February.  An  autopsy  was  performed 
by  Mr.  Walford,  the  particulars  of  which  are  given  in  his 
own  words  : — 

"  Fanny  S died  on   the   3rd,  and  assisted  by  Mr.  G. . 

May,  jun.,  and  Mr.  Fernie,  I  made  a  post-mortem  examina- 
tion. I  did  not  open  the  head.  The  thoracic  and  abdo- 
minal viscera  were  free  from  disease.  I  dissected  out  the 
tumour,  which,  had  the  whole  of  it  been  there,  would  have 
completely  encircled  one  side  (one-half)  of  the  lower  jaw ;  it 
extended  up  to  the  zygomatic  arch  and  downward  into  the 
neck.  The  gullet  was  free,  and  it  evidently  grew  into,  not 
from,  the  pharyngeal  region.  We  could  not  satisfactorily 
discover  its  origin.  The  portion  of  lower  jaw-bone  left  after 
the  operation  was  sawn  through  at  the  symphysis,  and  ex- 
hibits the  margins  of  the  tumour  on  the  periosteum,  which 
I  think,  must  be  considered  its  starting-point,  and  that,  as 
regards  treatment,  would  be  practically  the  bone."  (See 
Lancet,  March  6,  1858.) 

A  A 


354 


SARCOMA   OF  THE   LOWER   JAW. 


The  second  case  occurred  at  the  Great  Northern  Hos- 
pital, in  the  practice  of  Mr.  George  Lawson,  who  performed 
three  operations  with  the  hope  of  eradicating  the  disease, 
which,  however,  eventually  proved  fatal,  as  in  the  |)receding 
instance.  The  patient  was  a  young  woman  aged  seventeen, 
and  the  first  operation  was  performed  Octoher  4,  1858. 
She  had  then  what  might  be  termed  a  large  epulis  growing 
from  the  anterior  and  inner  surface  of  the  ascending  ramus 
of  the  lower  jaw  on  the  left  side,  extending  from  a  point 
near  the  angle  to  close  upon  the  condyle.  Mr.  Lawson  re- 
moved the  tumour  with  bone-forceps,  cutting  away  appa- 
rently all  its  bony  attachments.  About  six  weeks  after  the 
first  operation  a  small  elastic  mass  appeared  in  the  temporal 
fossa  of  the  affected  side,  but  tlie  jaw  was  apparently  free. 
This  Mr.  Lawson  excised^  but  found  that  the  growth  had 
evidently  sprung  from  its  original  site,  and  extending  up- 
wards, had  passed  beneatli  the  zygoma  into  the  temporal 
fossa.  The  third  operation  was  in  June,  1859,  when,  in 
consequence  of  the  great  size  the  tumour  had  attained,  the 
inability  of  the  girl  to  open  her  mouth,  and  the  great  diffi- 
culty she  experienced  in  deglutition,  Mr.  Lawson  removed  a 
portion  of  the  inferior  maxilla,  sawing  through  the  bone  in 
front  of  the  angle,  and  then  disarticulating.  Upon  the 
removal  of  this  portion  of  bone  (fig.  165),  it  was  found  that 

Fig.  1G5. 


the  tumour  had  formed  so  many  attachments  to  the  perio- 
steum of  the  bones  forming  the  base  of  the  skull,  that  the 
operator  was  compelled  to  leave  some  of  the  disease  behind. 
By  the  end  of  November,  1859,  the  tumour  had  again 


SPINDLE-CELLED   SARCOMA. 


355 


grown  to  a  large  size,  and  from  the  space  it  occupied  in  her 
mouth  interfered  much  with  her  taking  nourishment.  It  now 
began  to  soften  and  to  ulcerate  on  its  surface,  both  externally 
and   within    the    mouth,    and    occasionally   very   alarming 

Fig.  166. 


haemorrhages  would  take  place,  so  as  to  threaten  imme- 
diate dissolution,  but  from  all  these  she  rallied ;  within  the 
mouth  large  sloughs  would  occasionally  separate,  allowing 
her  to  recruit  her  health  by  enabling  her  to  take  additional 
nourishment.  She  died  early  in  1860,  worn  out  and  greatly 
emaciated.  The  drawing  (fig.  166),  for  which  I  am  indebted 
to  Mr.  Lawson,  shows  the  terrible  deformity  as  seen  after 

A  A  2 


356  SAKCOMA  OF  THE  LOWER  JAW. 

death.  The  preparation  is  in  the  Museum  of  the  College 
of  Surgeons  (2230  A).      (See  Fatliological  Transactions,  xi.) 

In  Mr.  Lawsou's  case,  repeated  careful  examinations  of 
the  tumour  proved  it  to  be  of  the  so-called  recurrent  fibroid 
character,  and  the  rough  and  thickened  condition  of  the  peri- 
osteum covering  the  portion  of  bone  which  was  removed, 
showed  clearly  the  site  from  which  the  tumour  grew.  Mr. 
Holt's  case,  which  is  remarkably  similar  in  all  essential 
points,  is  reported  as  one  of  malignant  disease ;  but  from 
personal  observation,  I  believe  it  to  have  been  an  example 
of  recurrent  fibroid  disease,  rather  than  any  form  of  true 
cancer.  The  two  cases  are  as  nearly  alike  as  they  could 
possibly  be,  and  were  doubtless  of  the  same  nature. 

The  treatment  of  this  form  of  disease  must  be  unsatis- 
factory. The  tendency  to  invade  the  tissues  continuous 
with  and  contiguous  to  the  original  seat  of  the  disease,  ren- 
ders any  operative  interference  of  doubtful  utility.  Still 
the  only  hope  for  the  patient  is  complete  extirpation  of  tlie 
disease  at  an  early  period,  and  the  operation  should  include 
tlie  entire  thickness  of  the  bone  from  which  the  growth  arises. 

The  following  museum  specimens  of  recurrence  of  the 
spindle-celled  sarcoma,  after  complete  removal,  may  be  con- 
veniently noticed  here. 

In  the  Museum  of  the  College  of  Surgeons  is  a  prepa- 
ration (2224)  of  the  right  side  of  a  lower  jaw,  from  the 
angle  to  the  bicuspid  tooth,  which,  with  a  tumour  upon  it, 
was  removed  by  Mr.  Liston.  The  tumour,  which  measures 
about  two  inches  in  its  greatest  diameter,  is  situated  almost 
entirely  on  the  anterior  surface  of  the  jaw,  projecting  for- 
wards and  upwards,  and  extending  along  nearly  the  whole 
length  of  the  portion  removed.  The  greater  part  of  the 
tumour  consists  of  a  pale,  firm,  and  compact  substance  :  at 
its  base  it  is  osseous,  and  so  closely  attached  to  the  anterior 
surface  of  the  jaw,  from  whicli  it  aj)pears  to  have  risen,  that 
the  outline  of  the  latter  can  scarcely  be  made  out.  The 
patient  was  a  woman  of  thirty,  who  had  had  a  blow  on  the 
clieek  nine  years  before  the  tumour  appeared.  Its  growth 
was  accompanied  by  lancinating  pain  in  the  jaw  and  con- 


MYELOID   SARCOMA.  357 

tinual  headache.  It  was  removed  five  montlis  after  its  lirst 
appearance.  No  portion  of  the  disease  appeared  to  have 
been  left,  but  the  growth  reappeared  in  the  ramns,  and  ne- 
cessitated its  removal  by  disarticulation  ten  months  after- 
wards (2225). 

In  St.  Bartholomew's  Hospital  Museum  is  a  specimen 
(I.  442)  of  a  tumour,  for  which  the  right  side  of  the  jaw 
from  the  angle  to  the  sympliysis  was  removed.  The  morbid 
growth  consists  of  a  grey,  dense,  fibrous  substance  originating 
from  the  alveolar  border,  and  from  the  outer  surface  of 
the  jaw.  Part  of  the  alveolar  border  of  the  jaw  has  been 
absorbed ;  and  in  this  situation  the  morbid  growth  appears 
to  extend  into  the  bone,  which  is  harder  than  usual.  It 
was  removed  from  a  woman  aged  thirty.  Subsequently  a 
tumour  formed  in  the  side  of  the  neck  immediately  below 
the  seat  of  the  operation,  which  ultimately  proved  fatal  by 
the  ulceration  and  sloughing  which  took  place  in  it.  A 
portion  of  this  was  connected  with  the  jaw,  and  a  section 
shows  it  to  consist  of  a  firm  fibrous  substance. 

Myeloid  Sarcoma  is  frequently  met  with  in  the  lower  jaw, 
and  it  was  here  that  the  disease  occurred  in  the  case  from 
which  Sir  J.  Paget  drew  his  description.  The  case  is  quoted 
by  Mr.  Stanley  (o]).  cit.  p.  184)  as  an  example  of  "  tumour 
of  bone,  composed  of  a  soft,  very  vascular  substance,  having 
the  characters  of  erectile  tissue,"  but  his  general  description 
corresponds  precisely  to  that  of  Sir  J.  Paget.  Pigs.  1  and 
2  of  Plate  13  in  Mr.  Stanley's  atlas  show  the  tumour  in 
situ  and  a  section  of  the  jaw  after  removal.  '■'  The  patient 
was  a  boy  in  St.  Bartholomew's  Hospital,  and  the  growth 
occupied  the  symphysis  of  the  lower  jaw,  and  protruding 
into  the  mouth  presented  a  very  vascular  surface  of  a  mottled 
red  and  purple  colour,  resembling  the  exterior  of  some  nasvi. 
The  tumour  was  not  tender  to  the  touch,  and  had  not  been 
accompanied  by  pain ;  it  was  once  destroyed  by  caustic  to 
the  level  of  the  alveolar  border  of  the  jaw,  but  was  quickly 
reproduced ;  it  was  then  wholly  removed  with  the  portion  of 
the  jaw  in  which  it  originated,  and  the  cure  was  permanent. 
The  morbid  substance  was  found  imbedded  in  the  cancellous 


^58 


SARCOMA  OF   THE  LOWER  JAW. 


texture  of  the  jaw ;  it  was  soft,  of  a  dark  red  colour,  closely 
resembling  the  tissue  of  healthy  spleen."    (Stanley,  p.  185.) 

Stanley  mentions  a  case,  very  similar  to  his  own,  recorded 
by  Dupuytren  in  his  Legons  Or  ales ;  and  in  the  Museum  of 
St,  Thomas's  thei'e  is  a  very  good  specimen  of  myeloid 
disease,  which  was  described  by  Sir  Astley  Cooper  ("  Surgi- 
cal Essays")  as  "  a  fungous  exostosis  of  the  lower  jaw,  which 

Fig.  167. 


formed  a  large  prominence  on  the  chin"  with  "  purple  fungi 
of  the  gums,"  occurring  in  a  woman  aged  thirty-two.  The 
preparation  shows  at  the  back  part  a  small  portion  of  firm, 
healthy  bone,  liaving  a  well-dulined  margin  and  not  sending 
out  any  spicula,  from  which  the  tumour  projects.  Around 
its  base  the  tumour  is  covered  with  integument ;  but  in  front 
the  latter  has  ulcerated,  allowing  the  growth  to  fungate 
through  the  ulcerated  aperture. 

A  valuable  preparation   is  in  the  College   of  Surgeons' 


MYELOID    SAHCOMA.  359 

Museum  (421)  of  myeloid  tumour  of  the  symphysis  and 
body  of  the  jaw,  removed  by  Mr.  Craven,  of  Hull,  from 
a  young  woman  of  eighteen,  who  made  a  good  recovery 
after  the  operation.  Figs.  167  and  168  show  very  satis- 
factorily the  appearance  of  the  specimen,  which  has  been 
divided  horizontally.  The  tumour  was  of  between  two  and 
three  years'  growth^  and  was  covered  with  healthy  mucous 
membrane.  Its  section  shows  a  well-marked  specimen  of 
myeloid  disease  imbedded  between  the  plates  of  the  lower 
jaw  ;  its  tissue  is  of  the  ordinary  friable  character,  resembling 
spleen,  but  somewhat  decolorized  by  immersion  in  spirit;  and 
it  is  intersected  by  fibrous  septa.  Two  cysts  may  be  seen  in 
the  section;  these,  as  mentioned  by  the  late  Mr.  H.  Gray 
{Medico -CJiirurgical  Transactions,  xxxix.),  being  of  frequent 
occurrence  in  myeloid  growths.  The  microscopic  examina- 
tion of  Mr.  Craven's  specimen  was  unsatisfactory,  owing  to  its 
previous  immersion  in  spirit,  but  there  can  be  no  question, 
from  the  naked- eye  appearances,  of  the  nature  of  the  growth. 

In  the  Museum  of  St.  George's  Hospital  are  four  speci- 
mens of  myeloid  disease  affecting  the  lower  jaw  (II.  166, 
167,  168,  169),  two  of  which  have  no  history;  the  others 
were  removed  from  girls  of  eight  and  five  years  respectively, 
of  whom  the  first  was  known  to  be  well  two  and  a  half  years 
afterwards.  In  the  Museum  of  University  College  are  three 
excellent  specimens,  removed  by  Liston  (680,  1,  2),  and  there 
are  three  in  St.  Bartholomew's  Hospital,  all  from  young 
persons. 

Myeloid  disease,  if  not  very  freely  removed,  may  recur, 
however,  as  in  a  case  of  Sir  William  Fergusson's,  which 
occurred  whilst  I  was  his  house-surgeon,  and  of  which  the 
particulars  will  be  found  in  the  Lancet,  June  13,  1857.  The 
patient,  a  young  woman  of  twenty-three,  had  undergone  a 
previous  operation,  but  it  was  doubtful  if  tlie  whole  of  the 
disease  had  then  been  removed.  She  presented  a  tumour  of  the 
right  side  of  the  lower  jaw  (fig.  169).  Sir  William  Fergusson 
removed  the  tumour  by  sawing  through  the  jaw  at  the  canine 
tooth  and  disarticulating,  but  the  patient  unfortunately  sank 
on  the  following  day  from  exhaustion.      The  following  is  a 


360  SARCOMA    OF    THE    LOWER  JAW. 

description    of  the  tumour,    which    proved   to  be   myeloid, 
extracted  from  the  published  report,  but  it  may  be  remarke  d 

Fjg.  169. 


that  the  colour  hardly  bears  out  the  diagnosis  of  myeloid 
disease  as  ordinarily  met  with : — "  It  has  been  developed 
within  the  bone,  which  it  has  expanded  into  a  thin  enve- 
lope of  compact  bony  tissue  clothing  its  exterior.  A  section 
showed  a  surface  of  a  clear  white  colour,  bathed  with  clear 
serum  (not  milky  when  scraped),  of  considerable  firmness, 
and  presenting  numerous  osteoid  deposits. — Minute  structure- 
It  is  almost  wholly  Imilt  up  of  small  cells,  whose  prevalent 
form  is  oval,  either  free  in  a  dimly  granular  matrix,  or,  here 
and  there,  contained  in  large  parent  cells,  resembling  those 
of  fcetal  marrow.      Very  delicate  fibres  occur  sparingly." 

A  remarkable,  and  I  believe  unique,  example  of  disease 
of  both  sides  of  the  lower  jaw,  the  microscopic  characters  of 
whicli  were  decidedly  myeloid,  was  formerly  under  my 
own  care,  of  which  the  following  are  the  brief  particulars. 
The  patient,  a  l)oy  of  seven  and  a  half,  whose  j^ortrait  is 
shown  in  fig.  170,  presented  a  remarkable  enlargement  of 
botli  sides  of  the  lower  jaw,  givinft'  his  face  a  very  square 
appearance.  The  affection  had  come  on  gradually  and  pain- 
lessly from  the  age  of  a  year  and  a  half,  and  at  the  time  I 


CHONDBO-SARCOMA. 


36  L 


operated  upon  him  the  width  of  tlie  jaw,  as  measured  with 
callipers,  was  five  inches,  the  width  of  an  average  adult  jaw 
being  only  four  inches.  The  growtlis  were  evidently  pro- 
jections from  the  outer  surfaces  of  the  angles  of  the  jaws, 
the    inner    surface    of    the    lione    being    natural,   and  the 


Fig.  170. 


Fig.  171. 


mucous  membrane  of  the  mouth  not  interfered  with.  In 
September  and  October,  1867,  I  removed  the  right  and 
afterwards  the  left  tumour  through  incisions  behind  the 
margin  of  the  jaw,  and  without  opening  into  the  mouth. 
The  main  part  of  each  projection  was  sawn  off  the  jaw, 
and  are  now  in  the  College  of  Surgeons'  Museum  (2232), 
closely  resembling  large  mussel -shells  filled  with  a 
cartilaginous-looking  substance,  which,  however  (and  espe- 
cially some  darker  portions)  gave  distinct  microscopic  evi- 
dence of  myeloid  structure.  A  good  deal  of  this  material, 
which  seemed  to  fill  the  interior  of  the  bone,  was  gouged 
away,  and  the  symmetry  of  the  face  restored  as  far  as 
possible.  The  boy  made  a  good  recovery,  and  fig.  171,  from 
a  photograph,  shows  his  condition  three  months  after  the 
second  operation,  and  there  appears  to  have  been  no  ten- 
dency to  recurrence.  The  case  is  given  in  detail  in  the 
Appendix,  Case  XIII. 

Cho7idro-sarco7na  is   characterized  by   rapidity  of  growth 


362  SARCOMA   OF   THE   LOWER   JAW, 

and  by  early  recurrence  after  removal.  The  primary  tumour 
is  mainly  encliondroma,  but  the  recurrent  growths  are  cliieliy 
composed  of  small  round-celled  sarcoma,  which  tend  to  pro- 
duce internal  deposits  through  the  vascular  system. 

The  following  good  illustration  of  the  disease  occurred 
under  my  own  care.  A  woman,  aged  forty-four,  was  ad- 
mitted into  University  College  Hospital  on  April  11,  1877, 
with  the  following  history  : — She  first  noticed  a  swelling 
connected  with  the  left  side  of  the  lower  jaw  nine  months 
before.  The  swelling  was  painful,  and  accomj)anied  by 
numbness  over  the  chin.  Twenty  years  before  she  had 
received  a  violent  blow  over  the  jaw,  when  attendant  in  a 
lunatic  asylum.  The  family  history  threw  no  light  on  the 
case.     The  patient  had  always  enjoyed  good  heialth. 

On  admission,  there  w^as  a  large  tumour  over  the  left  side 
of  the  lower  jaw,  and  firmly  connected  with  the  inner  and 
outer  surfaces  of  the  bone,  extending  from  an  inch  behind 
the  symphysis  to  the  angle.  The  growth  generally  was  firm 
and  elastic,  though  some  parts  were  much  softer  than  others. 
The  border  of  the  tumour  was  well  defined,  and  the  skin  was 
freely  movable  over  it.  A  nodule,  the  size  of  a  walnut, 
projected  between  the  teeth  into  the  cavity  of  the  mouth. 
The  patient  complained  of  shooting  pains  in  the  tumour, 
which  ran  along  the  lower  lip.  There  was  no  enlargement  of 
lymphatic  glands,  and  no  other  tumour.  The  general  health 
was  good.     The  patient's  appearance  is  shown  in  fig.  172. 

On  April  14th  I  removed  the  tumour  with  the  bone  in- 
volved, from  the  left  of  the  symphysis  to  an  inch  above  the 
angle,  and  the  patient  made  a  good  recovery. 

Eleven  weeks  after  discharge  she  was  readmitted.  The 
lower  borders  of  the  segments  of  the  previously  divided  jaw 
had  united  by  fibrous  union,  but  a  V-shaped  notch  existed 
at  the  upper  border  large  enough  to  admit  the  tip  of  the 
finger,  llecurrence  of  the  growth  liad  taken  place  in  con- 
nection with  both  divisions  of  bone.  There  was  a  tumour  as 
large  as  a  hen's  egg  beneath  the  chin,  but  this  could  not  be 
felt  through  the  mouth,  whilst  a  second  and  larger  one 
caused  bulging  of  the  left  cheek,  and  was  mainly  situated 


CHONDRO-SARCOMA. 


363 


over  the  ramus  of  the  jaw ;  it  projected  into  the  oral  cavity 
and  rendered  articulation  indistinct,  although  there  was  no 

Fig.  172. 


difficulty  in  deglutition.  The  skin  was  freely  movable  over 
both  masses ;  there  was  merely  a  linear  cicatrix  at  the  line 
of  the  old  incision.  The  lymphatic  glands  were  not  en- 
larged, and  the  general  health  was  good. 

A  second  operation  was  done  on  August  1,  1877.  It 
being  found  impossible  to  remove  the  tumour  by  the  mouth, 
I  made  an  incision  along  the  lower  border  of  the  jaw, 
from  two  inches  to  the  right  of  the  symphysis  for  a 
distance  of  six  inches.  The  lower  lip  was  dissected  from 
the  bone  and  turned  upwards,  and  the  jaw  sawn  through 
at  the  symphysis,  which  allowed  a  piece  on  the  left  to  be 
removed  with  growth  attached.  It  was  found  that  the 
whole  of  the  posterior  mass  could  not  be  removed,  as  it 
extended  deeply  into  the  pterygoid  region,  so  after  enu- 
cleating as  mucli  as  possible,  the  operation  was  not  further 
proceeded  with.  The  wound  was  syringed  out  with  strong 
solution  of  chloride  of  zinc,  and  then  plugged  with  lint. 


364  SARCOMA   OF   THE   LOWER   JAW. 

For  tlie  first  fourteen  days  the  wound  continued  to  heal 
rapidly,  but  at  tliis  time  it  commenced  to  fungate,  and  on 
the  twentieth  day  sharp  bleeding  ensued,  which  required  the 
actual  cautery  to  arrest  it.  Severe  pain  was  more  or  less 
constant,  and  the  discharge  very  fetid.  On  the  28th  the 
fungating  mass  reached  the  clavicle,  and  completely  hid  the 
left  side  of  the  neck  ;  haemorrhage  again  occurred,  and  the 
cautery  was  employed. 

In  spite  of  a  supporting  plan  of  treatment  the  general 
Iiealth  rapidly  failed,  the  patient  fell  into  a  semi- comatose 
condition,  got  more  and  more  asthenic  and  cachectic,  and 
died  on  the  forty-third  day  after  the  second  operation. 

Autopsy. — The  mass  of  growth  exteuded  from  the  zygoma 
downwards  for  over  seven  inches,  and  was  from  five  to  six 
inches  in  thickness.  Another  tumour  sprang  from  the  riglit 
segment  of  the  divided  jaw,  and  the  left  side  of  the  tongue 
and  floor  of  the  mouth  were  largely  invaded.  The  upper 
jaw  was  not  involved,  but  only  imbedded  in  the  growth, 
which  had  forced  itself  deeply  amongst  the  neighbouring 
parts,  where  the  veins  were  filled  with  firm  white  clots,  but 
no  growth  had  sprung  up  in  connection  with  their  walls. 
The  tumour,  on  section,  varied  in  colour,  being  yellowish- 
white  in  some  parts,  whilst  it  was  red  and  vascular  in  others, 
and  mottled  with  patches  of  extravasated  blood.  It  weighed 
2  lb.  3  oz.  There  were  two  nodules  of  secondary  growth  in 
the  left  lung,  and  three  larger  ones  in  the  right  lung.  One 
of  these  was  distinctly  seen  to  be  lying  in  the  course  of  a 
good-sized  branch  of  the  pulmonary  artery,  whose  walls 
were  expanded  over  it.  It  did  not  completely  block  the 
lumen  of  the  vessel,  and  on  its  surface  was  a  white  fibrinous 
deposit. 

The  mass  removed  at  the  first  operation  consisted  chiefly 
of  enchondroma,  with  a  dim  hyaliue  and  fibrous  matrix, 
but  interspersed  with  islets  of  round-celled  sarcoma.  The 
recurrent  masses  were  made  up  chiefiy  of  round  and  spindle- 
celled  sarcoma,  whilst  scattered  throughout  were  isolated 
portions  of  cartilaginous  tissue,  with  fibrous  matrix. 

Ossifying  sarcoma^  in   which  ossification  takes  place  ex- 


OSSIFYING   SARCOMA. 


365 


tensively  in  a  matrix  of  sarcomatous  tissue,  occurs  in  the 
lower  jaw,  and,  as  in  the  following  case,  presents  at  first 
most  of  the  characters  of  an  ordinary  osteoma.  Eig.  173 
shows   the  portion  of  lower  jaw  at  first  removed,  with  a 


Fig.  173. 


section  of  the  tumour,  which  it  is  difficult  to  distinguish 
from  ordinary  bone,  except  by  the  striation  seen  best  at  its 
margins.  The  rapid  recurrence  of  the  disease  in  a  soft  form 
showed  the  true  nature  of  the  case,  and  the  patient  died 
exhausted  within  a  year  of  the  first  operation. 

W.  G — ■,  aged  fifty,  was  admitted  into  University 
College  Hospital  on  May  9,  1881.  About  five  months 
previously  he  noticed  a  pricking  pain  about  the  left 
side  of  the  lower  jaw,  and  soon  a  lump  appeared  outside 
the  bicuspid  teeth  ;  it  grew  steadily  but  slowly,  until  one 
month  before  admission.  At  this  time  the  patient  had 
several  teeth  extracted,  and  the  increase  in  the  size  of  the 
growth  became  rapid  after  this  interference ;  there  was 
constant  gnawing  pain.  The  patient  believed  exposure  to 
cold  to  have  been  the  cause  of  the  swelling.  Both  his 
parents  died  of  "  old  age,"  and  had  no  kind  of  tumour. 

On  admission  the  lower  part  of  the  left  cheek  was  bulged 
outwards  considerably  by  a  very  hard  rounded  swelling, 
which  covered  the  outer  side  of  the  left  half  of  the  lower  jaw 


366  SARCOMA   OF  THE   LOWER   JAW. 

from  a  short  distance  in  front  of  the  angle  almost  to  the  left 
canine ;  the  lower  edge  of  the  bone  was  concealed  by  slight 
projection  of  the  mass  below  it ;  and  on  pressing  upwards  in 
the  submaxillary  region  a  considerable  swelling  could  be 
felt  on  the  inner  side  of  the  bone.  Altogether  the  impres- 
sion conveyed  to  the  fingers  was  that  the  growth  was 
central,  and  that  the  so-called  expansion  of  bone  had 
occurred  over  it.  No  teeth  were  present  on  the  left  side 
behind  the  canine,  the  alveolus  was  widened,  and  presented 
posteriorly  several  low,  rounded  swellings,  covered  by 
mucous  membrane,  soft  or  even  cystic ;  whilst  in  front  lay  a 
large  crater-like  ulcer,  at  the  bottom  of  which  no  bone  was 
bare.  The  tongue  and  floor  of  the  mouth  were  normal.  A 
small,  not  tender,  gland  could  be  felt  behind  the  angle  of  the 
jaw.  There  was  moderate  constant  pain  in  the  part,  much 
increased  by  hanging  the  head  down.  As  regards  general 
health  there  was  nothing  to  be  desired. 

On  May  11  ether  was  given,  and  the  growth  removed  by 
an  incision  from  the  left  angle  to  the  symphysis  ;  the  jaw 
was  sawn  through  to  the  left  of  the  symphysis,  the  soft  parts 
stripped  from  the  growth,  and  then  the  bone  was  divided 
near  the  angle.  The  wound  was  closed  by  wire  sutures, 
and  dressed  with  cotton  wool. 

The  wound  was  all  but  healed  on  the  eighth  day,  quite  so 
on  the  twentieth,  when  the  man  left  the  hospital  feeling  quite 
well. 

The  growth  was  smooth  on  the  surface,  and  covered  by  a 
thin  layer  of  fibrous  tissue  ;  it  was  subperiosteal,  not  central, 
and  on  the  inner  side  of  the  jaw  lay  two  long  oval  masses, 
parallel  to  the  mylo-hyoid  ridge — one  above,  one  below  it. 
A  section  of  the  large  outer  mass  showed  it  to  consist  of 
solid  bone,  much  denser  than  ordinary  cancellous  tissue, 
surrounded  by  a  margin  of  soft  greyish-yellow  tissue, 
nowhere  more  than  a  quarter  of  an  inch  thick.  Vertical 
striation  was  plain  in  this  border,  and  was  in  part  due  to 
spicules  of  bone.  On  the  alveolar  border  was  a  layer  of 
similar  soft  growth,  one-third  to  half  an  inch  thick.  Micro- 
scopically the  growth  consisted  of  rather  large  round  and 


OSSIFYING   SARCOMA.  367 

polygonal  cells,  surrounded  by  bands  of  spindle  cells,  and 
tracts  of  fairly  developed  connective  tissue ;  so  that  to  the 
naked  eye  a  section,  seen  by  transmitted  light,  was  made 
up  of  distinct  lobules.  The  above  description  refers  to  the  thin 
soft  layer  on  the  surface,  and  even  in  its  substance  dots  of  bone 
were  numerous ;  whilst  at  its  base  lay  a  large  mass  of  deep 
yellow  bone,  fairly  dense,  having  large  lacume  and  ill-deve- 
loped canaliculi ;  tumour  cells  occupied  the  cancellous  paces. 

Soon  after  leaving  the  hospital  the  patient's  face  swelled  a 
good  deal,  and  it  was  thought  that  recurrence  of  the  growth 
had  occurred  ;  but  a  sequestrum,  worked  out,  and  the  swell- 
ing subsided.  In  three  months,  however,  he  was  readmitted, 
having  had  a  distinct  recurrence  for  six  weeks,  with  much 
constant  pain.     His  health  was  still  very  good. 

On  September  6,  1881,  the  left  side  of  the  face  was  now 
swollen  from  two  inches  below  the  line  of  the  jaw  to  above 
the  level  of  the  ala  nasi,  and  from  the  symphysis  to  the 
lower  end  of  the  ramus  of  the  jaw.  On  looking  into  the 
mouth,  two  large  firm  masses  of  growth  were  found — one 
above  the  old  scar,  lying  in  the  cheek,  and  running  back 
almost  to  the  anterior  pillar  of  the  fauces;  the  other,  below 
the  scar,  occupied  the  floor  of  the  mouth.  They  were 
separated  by  a  deep  groove,  at  the  bottom  of  which  was  a 
little  ulceration  ;  elsewhere,  the  surfaces  of  the  growths  were 
slightly  lobulated  and  covered  by  mucous  membrane. 

No  large  glands  were  felt.  On  the  following  day  the 
whole  of  this  mass,  together  with  the  ramus,  coronoid  pro- 
cess, and  condyle  of  the  jaw,  were  removed  by  the  ordinary 
incision  for  the  removal  of  half  the  lower  jaw. 

The  patient  again  recovered,  without  any  bad  symptoms. 
The  hinder  part  of  the  wound  gaped  widely,  but  it  was 
healing  steadily,  and  there  was  no  obvious  recurrence  on 
October  8,  when  the  patient  left  the  hospital. 

The  left  angle  and  ramus  of  the  jaw  were  surrounded  on 
all  sides  by  masses  of  new  growth,  in  which  there  was  very 
little  bone,  as  far  up  as  the  base  of  the  coronoid  process. 
In  the  mass  which  lay  below  the  scar,  unconnected  with  the 
jaw,  there  was  a  large  proportion  of  bone.     Microscopically, 


3G8  SARCOMA    OF   THE    LOWER   JAW. 

the  growth  was  very  similar  to  the  primary  one ;  there  was 
less  division  into  lobules,  and  tlie  cells  were,  perhaps, 
smaller ;  the  bits  of  bone  seen  were  much  less  perfect. 

On  January  30,  1882,  the  patient  was  again  admitted, 
having  noticed  a  recurrence  of  the  growth  two  months.  The 
left  cheek  was  now  enormously  swollen,  and  the  angle  of  the 
mouth  pushed  forwards  by  a  mass  of  new  growth,  fungating 
into  the  mouth  along  the  line  of  the  jaw,  but  elsewhere 
covered  by  mucous  membrane.  The  old  wound  was  healed, 
but  for  an  ulcer  an  inch  and  a  half  by  half  an  inch,  round 
which  there  was  a  good  deal  of  firm  infiltration  at  its 
posterior  end.  The  growth  was  firm  and  elastic  at  some 
points,  bony  at  others,  adherent  to  the  symphysis,  but  not 
very  firmly.  The  whole  face  was  oedematous ;  the  left  tem- 
poral fossa  rather  full,  and  the  seat  of  nmch  pain.  The  man 
was  still  pretty  strong. 

On  February  2  the  old  incision  was  opened  up,  and  the 
main  part  of  the  growth  turned  out.  As  the  skin  was 
stripped  up,  the  hair-bulbs  could  be  seen  springing  out  of 
the  tumour  ;  then  a  piece  in  the  floor,  on  either  side  of  the 
frsenum,  was  removed,  and  the  two  ranine  arteries  cut  and 
tied.  When  the  tongue  had  been  drawn  forwards  by  a 
string,  the  symphysis  was  removed  to  just  beyond  the  right 
canine  tooth  ;  and,  finally,  an  attempt  was  made  to  remove 
the  posterior  end  of  the  tumour  ;  but,  as  it  here  seemed  to 
involve  the  tonsil  and  carotid  vessels,  and  to  spread  into  the 
temporal  fossa,  much  had  to  be  left. 

Again  the  patient  made  a  good  recovery.  The  anterior 
part  of  the  wound  healed,  but  the  posterior  gaped  widely, 
and  he  went  out  with  a  large  hole  here.  Pain  in  the  tem- 
poral region  continued.  He  died  at  home  on  April  5,  having 
been  able  to  walk  up  and  down  stairs  to  the  last.  The 
total  duration  of  the  disease  would,  therefore,  seem  to  have 
been  about  seventeen  montlis.  A  section  from  the  second 
recurrence  was  more  densely  round-celled  than  either  of  the 
preceding  specimens  ;  slight  traces  of  lobulation  remained,  and 
there  was  a  large  amount  of  rudimentary  bone.  Throughout 
the  vessel-walls  were  formed  by  C(>lls  of  the  new  growth. 


369 


CHAPTEE  XXIV. 

MALIGNANT    TUMOURS    OF    THE   LOWER    JAW. 

Round-Gelled  Sarcoma  a-iid  Epithelioma. 

Round-celled  or  Medullary  Sarco7na  begins  usually  in  the 
interior  of  the  bone,  producing  rapid  expansion  of  it,  and 
ultimately  breaking  through  into  the  mouth,  and  also 
through  the  skin  of  the  face  if  allowed  to  proceed  un- 
checked. A  specimen  in  University  College  Museum  (666) 
is  a  good  example  of  the  disease.  The  morbid  growth 
projects  chiefly  on  the  outer  side,  and  its  most  prominent 
part  has  protruded  through  the  skin,  forming  an  overhanging 
nummular  projection  which  has  an  open  reticular  surface. 
On  the  inner  side  the  tumour  has  invaded  the  jaw,  in  places 
destroying  its  entire  thickness ;  the  growth,  however, 
scarcely  projects  into  the  mouth.  As  seen  on  the  divided 
surface,  it  is  composed  of  a  soft,  granular,  yellowish  basis, 
supported  and  parted  into  small  polyhedral  masses  by 
narrow  lines  of  fibrous  tissue ;  its  lunit  is  everywhere  de- 
finable. Microscopic  examination  shows  the  tumour  to 
have  all  the  characters  of  a  large  round-celled  sarcoma. 

Many  of  the  museum  specimens  hitherto  described  as 
medullary  cancer  are  really  examples  of  round-cell  sarcoma, 
and  the  following  case  of  Mr.  Liston's,  in  the  College  of 
Surgeons  (2280),  may  be  quoted  as  an  instance  of  the  size 
to  which  round-celled  sarcoma  may  grow.  "  Part  of  a  lower 
jaw,  including  the  left  condyle,  the  alveolus  of  the  right 
first  molar  tooth,  and  all  the  intermediate  parts  which,  with 
an  enormous  tumour  upon  them,  were  removed  by  operation. 
The  left  ascending  portion  and  side  of  the  jaw,  as  far  as  the 

B  B 


370         MALIGNANT   TUMOURS   OF   LOWER   JAW. 

canine  tooth,  are  completely  enclosed  by  the  tumour,  and  it 
covers  both  surfaces  of  the  jaw  as  far  as  the  right  canine 
tooth.  A  round  lobulated  mass  projects  downwards  and 
forwards,  and  in  the  opposite  direction  the  tumour  projects 
into  the  mouth  witli  a  rough  fungous  surface,  in  which  a 
displaced  molar  tooth  is  seen.  The  interior  of  the  tumour 
is  indistinctly  lobulated,  composed  of  round  masses  con- 
nected by  cellular  tissue,  and  of  a  soft  texture ;  it  is  in- 
vested by  a  thick  capsule." 

I  had  under  my  care  a  very  interesting  case  of  medullary 
sarcoma  of  the  lower  jaw,  in  a  little  girl,  aged  five — one  of 
a  numerous  and  healthy  family,  who  was  in  perfect  health 
until  seven  weeks  before  I  saw  her.  The  mother  then 
noticed  that  the  second  temporary  molar  tooth  on  the  right 
side  was  loose,  and  the  gum  swollen;  and  a  tumour  de- 
veloped so  rapidly,  that  when  I  saw  her  the  side  of  the  face 

Fio.  174.    • 


was  considerably  enlarged,  and  a  large  fungous  mass  pro- 
truded into  the  mouth.  On  September  10,  1867,  I  re- 
moved the  right  side  of  the  jaw  from  close  to  the  symphysis 
to  the  articulation,  and  the  preparation  is  now  in  the 
Museum  of  the  College  of  Surgeons  (1057  A).  The  structure 
of  the  growth  was  distinctly  medullary.  The  child  made  a 
perfect  recovery,  and  was  well  for  six  weeks,  when  a  small 
srowth  was  noticed  within  the  cheek,  which  made  such 
rapid  progress  that  in  four  days,  when  she  was  brought  up 
to  me  again,   there   was  a  tumour   filling  the  cheek,  and 


ROUND-CELLED    SARCOMA.  371 

involving  the  remaining  portion  of  the  jaw  as  far  as  the 
canine  toothy  and  a  fungus  had  been  thrown  out  through  a 
portion  of  the  old  cicatrix. 

On  Oct.  26,  1867,  I  removed  the  whole  of  the  disease 
again,  cutting  the  jaw  on  the  left  side  immediately  in  front 
of  the  second  molar  tooth,  and  removing  the  whole  of  the 
skin  involved  in  the  fungus.  The  patient  made  a  good  reco- 
very, and  fig.  174,  drawn  from  a  photograph  taken  seven 
weeks  after  the  second  operation,  shows  her  then  con- 
dition, which  was  quite  satisfactory,  there  being  no ,  evidence 
whatever  of  return,  and  very  slight  deformity,  considering 
the  amount  of  jaw  removed. 

The  second  growth,  which  was  even  more  markedly  me- 
dullary than  the  first,  is  preserved  with  it. 

The  child  continued  in  perfect  health  to  the  end  of  the 
year,  but  early  in  January,  1868,  the  disease  reappeared,  both 
at  the  symphysis  and  in  the  masseteric  region  on  both  sides. 
Coupled  with  this  there  was  loss  of  appetite,  great  exhaustion, 
and  irritability  of  the  system ;  and  the  poor  child  gradually 
sank,  and  died  on  Feb.  9,  a  little  more  than  six  months  after 
the  first  appearance  of  the  disease.  The  full  particulars  of 
this  case  will  be  found  in  the  Appendix  (Case  XIV.). 

This  case  appears  to  me  of  considerable  interest,  since  it 
shows  the  advantage  of  surgical  interference,  even  under 
desperate  circumstances.  If  the  first  growth  had  not  been 
removed,  the  patient  would  have  been  shortly  destroyed  by 
the  fungus  in  the  mouth,  whereas  the  operation  gave  her 
six  weeks'  immunity  from  suffering.  The  return  of  the  dis- 
ease was  of  such  a  rapid  nature,  that  it  would  in  a  very  few 
days  have  destroyed  the  patient  by  haemorrhage  from  the 
fungus  which  had  already  begun  to  form  in  the  skin ;  but 
the  second  operation  again  relieved  her,  and  restored  her  to 
comfort  and  apparent  health  for  more  than  two  months. 
Wlien  the  disease  finally  appeared  on  both  sides  of  the  face, 
it  was  obviously  beyond  surgical  control,  and  rapidly  de- 
stroyed the  patient.  The  relief  which  the  operations 
afforded  was,  however,  gratefully  acknowledged  by  the  friends 
of  the  little  patient. 

B  B  2 


372         MALIGNANT   TUMOURS   OF   LOWER    JAW. 

Epithelioma  occurs  in  the  lower  jaw  in  two  forms,  the 
columnar  and  the  squamous.     Columnar  epithelioma  occurs 
in  connection  with  multilocular  cysts  and  with  single  cysts, 
and  has  been  already  fully  discussed  (p,  205).     Squamous 
epithelioma  is  the   more  common  form   of  disease,  and  is 
found  both  in  connection  with  ulceration  of  the  gums  (p.  251) 
and  as  a  tumour  of  the  jaw.      The  following,  under  my  own 
care,  is  a  typical  case  of  the  latter  form  of  the  disease.     A 
man,  aged  fifty-six,  first  noticed  a  swelling  in  his  face  four 
months  before  his  admission ;  he  used  to  have  toothache, 
and  had  lost  all  the  teeth  behind  the  left  lateral  incisor  in 
the  lower  jaw.     When  first  noticed,  the  tumour  was  about 
the  size  of  a  small  walnut,   and  was  situated  on  the  left 
ramus  near  the  angle  of  the  jaw.     It  was  not  painful  or 
tender  to  the  touch,  but  grew  steadily.     On  admission  to 
University  College  Hospital  there  was  on  the  left  side  of  the 
lower  jaw  a  rounded,  smooth  swelling,  which  extended  from 
the  middle  of  the  vertical  ramus  of  the  jaw  to  the  level  of 
the  hyoid  bone  below,  and  forwards  nearly  to  the  symphysis. 
The  swelling  was  firm  and  inelastic,  and  the  skin  over  it 
was  normal,  except  that  it  was  slightly  reddened  over  the 
anterior  half  of  the  growth.    Inside  the  mouth  the  growth 
projected  as  a  large  red  roundish  mass,  with  the  surface 
flattened  and  sloughy.     It  reached  as  far  backward  as  the 
vertical  ramus,  and  encroached  upon  the  floor  of  the  mouth. 
I  removed  the  tumour,  with  the  portion  of  the  lower  jaw 
implicated,  by  dividing  the  lower  lip  in  the  median  line 
and  carrying  an  incision  beyond  the  angle  of  the  jaw.     The 
jaw  was  sawn  to  the  right  of  the  median  line,  between  the 
incision  and  the  canine  teeth,  and  the  tongue  being  secured 
with  a  thread,  tlie  bone  was  disarticulated  on  the  left  side 
with  some  little  difficulty,  owing  to  the  tumour  breaking 
away   from    the    upper  part.     Consequently   the    coronoid 
process  was  nipped  off  with  bone-forceps,  and  an  elevator 
was  used  to  lift  the  condyle  out.     There  was  very  little 
bleeding,    and    only  one    or   two    ligatures    were    applied. 
The  wound  was  sprinkled  with  iodoform,  and  brought  together 
with  wire  sutures,  drainage  being  provided  for. 


EPITHELIOMA   OF  LOWER   JAW.  373 

The  patient  made  an  uninterruptedly  good  recovery  and 
left  the  hospital  in  thirty  days. 

The  part  removed  consisted  of  the  remains  of  the  left  half 
of  the  bone,  the  part  between  the  vertical  ramus  and  the 
central  incisors  being  almost  entirely  destroyed  by  the 
growth,  only  a  shell  of  bone  remaining  at  each  end.  On 
section  the  growth  was  of  a  dead  white  colour  where  oldest, 
with  a  firm  margin  advancing  into  the  surrounding  tissues. 
It  consisted  of  a  fibrous  stroma,  in  which  were  scattered 
numerous  leucocytes  and  spindle  cells,  with  large  masses  of 
squamous  epithelium  cells,  many  of  which  were  collected  into 
bird's-nest  groups.  The  specimen  is  in  University  College 
Museum. 

The  general  characters  of  squamous  epithelioma  of  the 
jaw  are  well  seen  in  the  foregoing  case.  Eapidity  of  growth, 
with  destruction  of  the  bone,  and  fungation  into  the  mouth, 
are  the  leading  characteristics,  and  nothing  but  early  and 
free  removal  offers  any  chance  of  relief.  In  the  above  case 
the  jaw  in  its  upper  part  was  apparently  healthy,  but  I  had 
no  hesitation  in  disarticulating  so  as  to  be  thoroughly  beyond 
the  disease,  and  I  also  went  well  into  healthy  bone  at  the 
point  of  section  so  as  to  avoid,  as  far  as  possible,  all  risk  of 
recurrence. 

The  question  of  the  necessity  for  the  removal  of  large 
portions  of  bone  in  cases  of  cancer  of  the  lower  jaw  may  be 
here  referred  to.  Some  surgeons  maintain  that,  in  a  case  of 
cancer,  it  is  necessary  to  amputate  at  the  joint  above  the 
disease  in  order  to  obtain  immunity.  But,  if  this  doctrine 
is  to  be  carried  out  fully,  the  entire  lower  jaw  should  be 
removed  for  disease  of  one  side,  for  though  the  bone  was 
originally  developed  in  two  halves,  there  is  nothing  to  pre- 
vent malignant  disease  spreading  across  the  symphysis,  as 
was  seen  in  the  case  of  epithelioma  under  my  own  care. 

It  certainly  is  essential  that  in  dealing  with  cancer  of 
the  lower  jaw  the  surgeon  should  go  beyond  the  disease, 
and  not  meddle  with  the  growth  itself.  A  preparation 
(College  of  Surgeons'  Museum,  2231  A),  is  an  instance 
in  point.     It  was  removed,  post-mortem,  from  a  man  who 


374         MALIGNANT    TUMOURS    OF    LOWER   JAW. 

died  under  my  care,  with  periosteal  medullary  sarcoma  of 
the  right  side  of  the  lower  jaw.  He  had  a  swelling  of 
the  gum  in  the  region  of  the  molar  teeth,  which  was 
thought  by  a  dentist  of  repute  to  depend  upon  the  irritation 
of  some  stump  of  a  tooth.  The  growth  was  therefore  in- 
cised, and  a  prolonged  search  made  for  the  suspected  fang, 
without  result.  The  effect  of  this  treatment  was  to  excite 
very  considerable  action  in  the  parts,  the  tumour  rapidly 
increased  in  size,  discharging  large  quantities  of  fetid  matter, 
and  a  considerable  piece  of  necrosed  bone  could  be  detected 
with  the  probe.  The  patient,  when  he  came  under  my 
notice,  was  not  in  a  condition  to  bear  any  operative  inter- 
ference, and  shortly  died.  The  preparation  shows  a  malig- 
nant tumour  surrounding  the  greater  part  of  the  right  side 
of  the  jaw,  the  bone  within  being  in  a  state  of  necrosis, 
and  the  condyle  and  j)art  of  the  coronoid  process  having 
entirely  disappeared. 

The  lower  jaw  is  liable  to  be  invaded  by  epithelioma 
spreading  to  it  from  the  tongue  and  lip,  and  may  be  affected 
by  both  epithelioma  and  sarcoma  developed  in  the  neigh- 
bouring lymphatic  glands. 

On  more  than  one  occasion  I  have  found  epithelioma  of 
the  anterior  part  of  the  tongue  attached  to  and  infiltrating 
the  central  portion  of  the  lower  jaw,  and  have  been  obliged 
to  cut  out  the  incisive  region  with  good  result.  The  most 
remarkable  case  was  one,  the  details  of  which  will  be  found 
in  the  Appendix  (Case  XV.),  of  a  man,  aged  fifty-two,  who 
was  under  my  care  in  1875  with  extensive  epithelioma  of 
the  front  of  the  tongue,  which  was  firmly  fixed  by  its  tip 
to  the  lower  jaw,  with  great  enlargement  of  the  sub- 
maxillary glands  and  infiltration  of  the  submaxillary  tissues. 
He  suffered  acutely  from  occipital  pain,  which  it  is  difScult 
to  explain,  and  was  willing  to  submit  to  any  operation  for 
relief.  I  divided  the  jaw  on  each  side  1^  inch  from  the 
symphysis  and  then  removed  the  front  of  the  tongue,  the 
centre  of  the  jaw,  and  all  the  sublingual  structures  with  the 
galvanic  ^craseur  (University  College  Museum,  1023).  The 
patient  made  a  rapid  recovery,  the  two  portions  of  jaw  fell 


EPITHELIOMA    OF    LOWER    JAW.  375 

together,  and  are  now  united  at  an  angle  by  tough  fibrous 
tissue,  and  the  man,  who  was  alive  and  well  in  1883,  has 
covered  the  deformity  by  growing  a  beard. 

In  January,  1879, 1  performed  nearly  as  extensive  an  opera- 
tion on  a  man,  aged  sixty-eight,  removing  the  lower  jaw  from 
the  right  incisors  to  the  left  angle,  for  extensive  epithelioma 
of  the  jaw  and  floor  of  the  mouthy  the  patient  making  a 
good  recovery  and  being  in  perfect  health  two  years  later, 
but  dying  with  recurrence  of  the  disease  eventually  {Lancet, 
November  20,  1880). 

In  the  cases  of  recurrent  epithelioma  of  the  lip,  when 
the  disease  shows  itself  in  the  submental  glands,  which 
become  adherent  to  and  implicate  the  bone,  it  is  possible  to 
give  relief,  for  a  time  at  least,  by  sawing  out  the  portion  of 

Fig.  175. 


bone  involved,  as  I  did  in  an  old  man  in  May,  1876. 
In  two  instances  I  have  sawn  off  the  chin  only,  without 
breaking  the  line  of  the  alveolus,  or  opening  the  cavity  of 
the  mouth.     Tig.  175  shows  the  first  patient  ou  whom  I  per- 


376        MALIGNANT  TUMOURS   OF   LOWER   JAW. 

formed  the  operation,  and  tlie  details  of  the  case  will  be 
found  in  the  Appendix  (Case  XVI.). 

Sarcomatous  growths  in  the  submaxillary  lymphatic 
glands  tend,  after  a  time,  to  implicate  the  lower  jaw,  of  which 
it  may  be  necessary  to  remove  a  portion  with  the  tumour. 
A  specimen  (2254)  in  the  Museum  of  the  College  of 
Surgeons  is  the  left  half  of  a  jaw-bone,  the  body  of  which 
has  been,  to  a  great  degree,  destroyed  by  the  growth  of  a 
firm  substance,  which  appears  to  have  been  developed  on 
the  exterior  of  the  bone,  and  to  have  gradually  produced 
ulceration  and  necrosis  of  it.  At  the  angle  of  the  jaw, 
adjacent  to  the  growth,  the  bone  is  deeply  and  irregularly 
ulcerated,  and  near  the  symjDhysis  several  portions  of  it  are 
completely  detached.  The  patient  was  a  man  of  forty- five, 
and  the  disease  began  in  a  hard  enlargement  in  the  situation 
of  the  submaxillary  gland.  After  increasing  for  a  year  it 
extended  into  the  mouth,  where  a  fungous  growth  protruded, 
and  subsequently  the  integuments  of  the  cheek  sloughed 
and  rapidly  ulcerated,  and  the  patient  died  exhausted. 
After  death  secondary  growths  were  found  in  the  lungs  and 
liver. 

By  the  kindness  of  Mr.  Wilkes,  of  Salisbury,  I  was  en- 
abled to  send  to  the  College  of  Surgeons'  Museum  (2251)  a 
tumour  near  the  angle  of  the  jaw,  for  which  that  gentle- 
man amputated  one-half  of  the  bone,  which  was  exhibited 
to  the  Pathological  Society  of  London,  in  May,  1862.  The 
patient  was  a  man  of  fifty,  who  had  a  globular  mass  below 
the  middle  of  the  horizontal  ramus  of  the  jaw,  adherent  to 
the  bone,  but  movable.  The  angle  of  the  ja\v  was  roughened 
near  the  growth.  After  removal  of  the  half  of  the  jaw  the 
tumour  was  found  to  be  enclosed  in  a  thick  fibrous  capsule, 
connected  with  the  periosteum.  Mici'oscopically  the  tumour 
was  composed  of  very  small  round  cells,  with  very  little 
stroma.  It  was  probably  a  lympho-sarcoma,  and  may  have 
originated  in  the  submaxillary  lympliatic  glands. 

Mr.  Coates,  of  Salisbury,  was  also  kind  enough  to  place 
at  my  disposal  another  specimen  of  growtli  connected  with 
the  lower  jaw,  which  is  also   in  the  College  of   Surgeons' 


EPITHELIOMA   OF   LOWER   JAW.  377 

Museum  (2352).  The  patient,  a  man  aged  sixty-seven,  was 
admitted  into  the  Salisbury  Infirmary  in  November,  1863, 
v^'ith  a  tumour  of  the  right  side  of  the  lower  jaw,  for  which 
amputation  of  one-half  of  the  bone  was  performed  by  Mr. 
Coates.  The  patient  unfortunately  sank  eleven  days  after 
the  operation.  The  tumour  is  closely  connected  with  the 
periosteum  on  the  inner  surface  of  the  jaw.  It  is  of  the 
size  of  a  chestnut,  and  on  section  shows  a  small  cavity  in  the 
interior.  In  minute  structure  it  consisted  of  rounded  masses 
of  coalescent  round  or  oval  epithelium  with  large  nuclei,  and 
not  of  the  pavement-cell  type.  Tlie  stroma  was  not  abun- 
dant, and  was  of-  a  distinctly  fibrous  nature.  The  growth 
probably  arose  in  some  structure  external  to  the  jaw. 

I  have  recently  had  under  my  care  a  man  of  sixty-six, 
who  noticed  some  stiffness  of  the  neck  for  about  six  months 
before  he  discovered  a  tumour  near  the  left  angle  of  the 
jaw.  "When  he  came  under  my  care,  three  months  later, 
there  was  on  the  left  side  of  the  face  a  new  growth  in- 
volving the  angle  and  horizontal  ramus  of  the  jaw,  and 
reaching  to  the  sterno-mastoid  behind  and  the  level  of  the 
thyroid  cartilage  below.  The  skin  was  reddened  and  ad- 
herent, and  at  one  point  had  given  way.  There  was  no 
ulceration  of  the  mucous  membrane  of  the  mouth,  and  the 
glands  in  the  neck  were  not  enlarged.  I  isolated  the 
growth  by  a  curved  incision,  including  the  implicated  skin, 
and  then  sawed  through  the  lower  jaw  behind  the  second 
bicuspid  tooth,  and  immediately  above  the  angle.  The 
patient  vomited  persistently  after  the  operation,  and  sank 
on  the  seventh  day. 

The  specimen  shows  that  the  lower  jaw  is  surrounded  by 
a  new  growth  which  clings  tightly  to  the  periosteum^  but 
does  not  reach  up  to  the  edentulous  alveolar  border.  The 
hard  bone  of  the  lower  border  of  the  jaw  is  destroyed,  and 
the  growth  penetrates  into  the  cancellous  tissue.  The  sub- 
maxillary gland  lying  on  the  inner  surface  of  the  mass  is 
being  gradually  absorbed,  the  growth  pressing  on  its  inner 
surface.  The  surface  of  the  tumour  (fig.  176)  is  surrounded 
by  a  distinct  outline,  separating  it  from   the   neighbouring 


378 


MALIGNANT    TUMOURS    OF    LOWER   JAW. 


fat.  It  appears  to  have  commenced  in  the  lymph-gland  on 
the  parotid,  for  of  this  there  is  no  trace  whatever;  the 
remains  of  the  submaxillary  salivary  gland  appear  perfectly 
healthy. 

Microscopically  the  growth  proved  to  be  squamous  epi- 
thelioma, consisting  of  the  ordinary  stroma,  through  which 

Fig,  176. 


were  scattered  ordinary  squamous  epithelial  cells  with 
"  bird's-nest"  fairly  well  marked.  It  is  a  little  difficult  to 
explain  this  occurrence  of  squamous  epithelioma,  since  the 
mouth  was  in  no  way  involved,  and  so  far  as  could  be  made 
out  there  was  no  primary  disease  elsewhere. 


379 


CHAPTEE   XXV. 

DIAGNOSIS    AND    TREATMENT    OF   TUMOURS    UF    THE 
LOWER    JAW. 

Diagnosis. — The  diagnosis  of  tumours  of  the  lower  jaw  is 
easier  than  is  the  case  in  the  upper  jaw.  Slowness  of  growth, 
hardness,  and  isolation  point  to  a  non-malignant  tumour, 
and  this  will  be  confirmed  if  there  is  no  tendency  to  fungate 
within  the  mouth,  and  no  enlargement  of  the  neighbouring 
lymphatic  glands.  Simple  tumours  of  the  lower  jaw,  if 
allowed  to  grow  unchecked,  may  after  a  time  burst  through 
the  skin,  and  thus  give  rise  to  a  fungating  mass,  which, 
however,  is  of  slower  growth  and  more  healthy  appearance 
than  the  malignant  fungus.  Eapidly  growing  tumours  are 
almost  invariably  cancerous,  and  the  only  chance  for  the 
patient  is  their  early  removal,  with  the  portion  of  bone 
implicated. 

The  prognosis  after  removal  of  tumours  of  the  lower  jaw 
is  more  favourable  than  elsewhere,  since,  owing  to  the 
anatomical  relations,  it  is  easy  to  get  rid  of  the  whole 
disease.  The  question  of  the  return  of  cancer  being  in- 
fluenced by  removal  of  one-half  of  the  bone  is,  as  already 
mentioned,  still  an  open  one. 

The  successful  recoveries  following  removal  of  large 
portions  of  the  lower  jaw  are  very  remarkable,  operations 
on  the  lower  jaw  being  as  a  rule  attended  by  little  constitu- 
tional disturbance.  Mr.  Cusack  removed  large  portions  in 
seven  cases,  with  only  one  fatal  result,  which  was  due  to 
erysipelas  and  oedema  of  the  glottis.  Dupuytren  operated 
in  twenty  cases,  with  only  one  death  resulting  from  the 
operation,  and  that  from  the  same  cause  as  in  Mr.  Cusack's 
fatal  case.     The  experience  of  modern  surgeons  is  equally 


380  OPERATIONS   ON   THE   LOWER   JAW. 

favourable.  AVheu  the  disease  is  of  ordinary  dimensions, 
and  the  patient  is  in  fair  health,  the  results  are  exceedingly 
satisfactory. 

Ojpcratiuns  on  the  Lotvcr  Jaw. — Small  tumours,  involving 
the  alveolus,  may  be  removed  with  bone-forceps  without  any 
incision  through  the  skin,  and  even  a  considerable  portion 
of  the  central  part  of  the  lower  jaw  may  be  removed  with- 
out incising  the  lip^  if  the  mucous  membrane  between  it 
and  the  bone  be  freely  divided  and  the  lip  drawn  well  down. 
The  large  forcejDS  figured  at  page  245  are  particularly  useful 
in  attacking  tumours  situated  in  the  molar  region  without 
external  incision,  and  the  gouge  and  chisel  should  be  freely 
employed  for  the  enucleation  of  benign  tumours  in  the  in- 
terior of  the  lower  jaw. 

The  late  Mr.  Maunder  {Medical  Times  and  Gazette,  July, 
1874)  removed  two  fibrous  timiours  of  the  lower  jaw  of 
considerable  size  without  any  external  incision,  separating 
the  soft  parts  with  a  raspatory,  and  sawing  the  bone  in  front 
of  and  behind  the  tumour.  The  principal  difficulty  in  these 
operations  was  not  so  much  the  separation  of  the  tumour  as 
its  "  delivery"  through  the  mouth,  which  was  slightly  split 
in  one  instance.  Fortunately  the  hemorrhage  in  both  cases 
was  slight  and  the  patients  did  well,  but  another  surgeon 
who  adopted  the  proceeding  was  less  fortunate,  and  lost  his 
patient  by  secondary  haemorrhage^  which,  considering  the 
close  proximity  of  tlie  facial  artery  and  the  necessary  division 
of  the  inferior  dental  artery,  is  not  very  surprising.  For 
my  own  part,  I  do  not  think  the  extra  trouble  and  risk 
of  the  proceeding  are  balanced  by  the  absence  of  a  scar, 
which,  in  the  majority  of  cases,  need  not  involve  the  lip, 
and  if  properly  placed  will  be  nearly  invisible  afterwards. 
The  same  may  be  said  of  the  so-called  "  sub-periosteal  re- 
sections" of  the  lower  jaw.  In  cases  of  necrosis  it  is,  of 
course,  advisable  to  preserve  all  the  periosteum,  and  in 
extracting  a  sequestrum  it  may  be  occasionally  necessary  to 
turn  aside  soft  parts  with  a  raspatory,  but  any  systematic 
stripping  of  periosteum  from  a  jaw  involved  in  a  tumour, 
is  not  only  impossible,  but,  if  undertaken,  will  surely  leave 


OPERATIONS   ON   TUB  LOWER   JAW.  381 

shreds  of  periosteum  with,  possibly,  some  portion  of  disease 
attached. 

In  order  to  operate  satisfactorily  within  the  mouth  it  is 
essential  that  the  jaws  should  be  kept  fully  asunder,  and  I 
have  found  nothing  so  convenient  for  the  purpose  as  a  simpl  e 
vulcanite  "  prop"  similar  to  that  used  by  dentists,  placed  in 
position  on  the  side  opposite  to  the  disease  before  the  adminis- 
tration of  chloroform.  A  string  attached  to  it  obviates  any 
danger  of  its  being  swallowed.  The  ingenious  gag  contrive  d 
for  dental  operations  by  Mr.  S.  J.  Hutchinson  (fig.  177) 
may  also  be  employed  for  the  same  purpose. 

Fig.  177. 


When  a  large  portion  of  the  body  and  ramus  has  to  be 
removed,  a  curved  iiicision  may  be  advantageously  carried 
along  the  posterior  margin  of  the  tumour,  so  that  the  scar 
may  be  well  out  of  sight  afterwards.  In  this  the  facial 
artery  will  be  necessarily  divided  at  the  anterior  border  of 
the  masseter  muscle,  and  it  is  ad\dsable  to  secure  both  ends 
immediately  with  ligatures,  or  the  patient  may  lose  a  con- 
siderable quantity  of  blood.  The  tissues  being  then  dissected 
off  the  tumour,  a  careful  examination  of  it  should  be  made 
to  see  if  it  be  possible  to  extract  the  tumour  by  removing 
the  external  plate  of  bone  with  the  gouge  and  bone-forceps, 
and  no  harm  can  come  of  such  an  attempt,  even  if  it  prove 
abortive,  since  no  vessel  of  importance  is  interfered  with. 
If  necessary,  however,  a  small  saw  can  be  applied  in  front 
of  and  behind  the  affected  portion,  which  can  then  be  readily 
isolated  and  removed. 


382  OPERATIONS    ON    THE    LOWER   JAW. 

In  making  these  sections  of  the  lower  jaw  it  is  better  not 
to  complete  one  before  the  other  is  begun,  because  of  the  loss 
of  resistance  consequent  upon  breaking  the  continuity  of  the 
bone ;  but  both  cuts,  being  carried  nearly  through  the  bone 
with  the  saw,  may  be  conveniently  completed  together  with 
the  bone-forceps. 

When  the  central  portion  of  the  lower  jaw  is  removed,  it  is 
well  to  take  precautionary  steps  to  avoid  the  possibility  of 
the  tongue  falling  back  and  suffocating  the  ]3atient.  A 
ligature  should  therefore  be  passed  through  the  tip  of  the 
tongue,  which  will  enable  a  trustworthy  assistant  to  keep  it 
drawn  forward  until  the  operation  is  completed.  The  liga- 
ture should  then  be  attached  to  one  of  the  hare-lip  pins  with 
which  the  wound  is  closed,  and  may  safely  be  cut  and  re- 
moved on  the  second  or  third  day.  In  all  cases  in  which 
the  inferior  dental  artery  will  be  divided,  the  operator 
should  be  provided  with  a  fine  Paquelin's  cautery  or  a  small 
plug  of  wood,  which  may  be  thrust  into  the  dental  canal 
to  stop  all  bleeding. 

Amputation  of  one  side  of  the  lower  jaw  can  be  conve- 
niently performed  through  an  incision  running  along  the 
posterior  margin  of  the  bone,  from  the  level  of  the  lobule  of 
the  ear  to  the  median  line,  where,  if  the  size  of  the  tumour 
renders  it  necessary,  a  vertical  incision  may  be  carried  through 
the  lip  (fig.  178).  The  facial  artery  having  been  secured,  the 
tissues  of  the  cheek  and  the  masseter  are  dissected  up,  M'ithout 
injuring  the  flap  and  without  prolonging  the  incision  uj)- 
wards,  by  which  the  facial  nerve  would  be  of  necessity 
divided.  A  tooth  having  been  extracted  at  the  point  where 
the  bone  is  to  be  divided,  this  is  effected  with  a  small 
straight-backed  saw,  and  the  bone  having  been  grasped  with 
the  "  lion  forceps,"  is  drawn  forcibly  outwards,  whilst  the 
knife  is  run  along  its  inner  side,  care  being  taken  to  keep 
close  to  the  bone,  so  as  not  to  endanger  the  submaxillary 
gland  or  lingual  nerve.  The  internal  pterygoid  muscle 
having  been  carefully  separated  from  the  bone,  forcible 
traction  is  to  be  made  upon  the  jaw,  so  as  to  depress  tlie 
coronoid  process,  which  by  a  few  touches  of  the  knife  is 


OPERATIONS    ON    THE   LOWER   JAW. 


383 


freed  from  the  fibres  of  the  temporal  muscle.  The  joint 
being  now  in  view,  the  knife  is  to  be  applied  to  the  front  of 
it,  when  the  condyle  will  be  at  once  dislocated,  and  the 
knife  can  be  carried  cautiously  behind  it,  so  as  to  isolate  it. 
A  forcible  wrench  of  the  bone  will  now  tear  through  the  few 
remaining  fibres  of  the  external  pterygoid  muscle,  and  the 

Fig.  178. 


bone  can  be  removed.  At  the  same  time  care  must  be 
taken  not  to  twist  the  jaw  outwards,  so  as  to  force  the  con- 
dyle and  neck  of  the  bone  against  the  internal  maxillary 
artery,  which  might  thus  be  torn. 

In  order  to  obviate  the  difficulty  which  often  occurs  at 
this  stage  of  tlie  operation.  Dr.  Gross  recommends  a  flat 
bone-elevator,  to  clear  the  coronoid  process  and  condyle,  and 
thus  avoid  all  danger  to  the  artery.  Having  employed  this 
plan  on  several  occasions  I  can  strongly  recommend  it. 
Mr.  Bryant  has  in  some  cases  dissected  up  the  periosteum 
and  slipped  the  condyle  out  of  it,  but  there  appears  to  be  a 


384  OPERATIONS   ON  THE   LOWER  JAW. 

danger  of  leaving  disease  behind  in  many  cases,  if  this  plan 
were  generally  adopted. 

In  the  case  of  small  tumours,  removal  of  one-half  of  the 
lower  jaw  is  sufficiently  easy,  but,  when  the  tumour  is  large, 
it  may  so  completely  wedge  in  the  ujDper  part  of  the  bone 
as  to  hinder  the  freeing  of  the  coronoid  process,  and  prevent 
dislocation.  Under  these  circumstances  the  best  plan  is  to 
use  the  bone-forceps  to  cut  off  the  coronoid  process,  or  to 
re-apply  the  saw  and  cut  of!  the  tumour  as  high  as  may  be, 
and  subsequently  to  remove  the  remaining  portion  of  jaw, 
if  the  disease  is  malignant,  but  not  otherwise.  Another 
complication  is  when  the  tumour  breaks  away  from  the 
upper  part  of  the  jaw  during  the  operation,  thus  rendering 
it  difficult  to  dislocate  the  condyle,  owing  to  the  want  of 
leverage.  The  "  lion-forceps"  of  Sir  William  Fergusson  is 
exceedingly  useful  here,  as  I  have  experienced  in  several 
cases. 

Wlien  one-half  of  the  lower  jaw  1ms  been  removed,  some 
inconvenience  is  experienced  from  the  remaining  portion 
being  drawn  inwards  by  its  muscles.  To  obviate  this,  Mr. 
Nasmyth,  of  Edinburgh,  originally  contrived  some  metallic 
caps  to  fit  the  teeth  of  the  upper  and  lower  jaws,  and  thus 
keep  the  bone  in  position.  Mr.  Listen  speaks  highly  of 
this  apparatus,  and  a  similar  contrivance  made  by  Mr. 
Cartwright  was  of  great  service  in  the  case  of  the  patient 
of  Sir  W.  Fergusson,  whose  portrait  is  shown  at  page  184. 
I  have  employed  a  double  vulcanite  cap  for  tlie  teeth  for  the 
purpose,  as  being  more  cleanly,  but  have  found  so  much 
pain  caused  by  the  constant  tension  of  the  muscles  of  the 
unaffected  side  wliich  are  left  without  opponents,  that  I  have 
abandoned  the  method  altogether,  and  am  content  to  allow 
the  remaining  portion  of  jaw  to  be  thrust  inwards,  as  it 
certainly  will  be  sooner  or  later. 

In  the  case  of  very  large  tumours,  necessitating  the  re- 
moval of  the  greater  part  of  the  lower  jaw,  the  direction  of 
the  incision  is  a  matter  of  considerable  importance.  Figs. 
179  and  180  show  the  incision  recommended  by  Sir  William 
Fergusson  in  cases  of  the  kind  ;  the  great  advantage  being 


VARIETY    OF   INCISIONS. 


385 


the  non-interference  witli  the  lip  (which  is  dissected  up  with 
the  integuments  of  the  chin),  and  the  fact  that  the  scar  is 
completely  hidden  afterwards.  On  the  other  hand,  this  in- 
cision necessitates  the  division  of  both  facial  arteries,  and  if 
disarticulation  on  one  side  is  requisite,  will  not  afford  good 
room  for  the  proceeding  without  danger  to  the  facial  nerve. 
In  a  case  of  very  large  osteo-sarcoma  of  the  lower  jaw,  already 
described,  I  preferred  an  incision  through  the  median  line 
of  the  lip,  and  was  able  to  dissect  the  flaps  back  with  great 
ease  and  rapidity,  and  to  avoid  cutting  either  of  the  facial 
arteries.     The  median  line  is,  after  all,  the  best  position  for  a 


Fig.  179. 


Fig.  180. 


cicatrix,  and  I  regard  the  division  of  the  lower  lip,  which 
always  readily  unites  again,  as  a  very  unimportant  matter. 

The  case  in  which  Mr.  Syme  removed  the  ramus  and 
condyle  of  the  jaw  without  opening  the  mouth,  through  .an 
incision  in  front  of  the  ear,  has  been  already  referred  to, 
and  Professor  Humphry  adopted  a  similar  incision  in  the 
case  in  which  he  excised  the  condyle  of  the  lower  jaw,  which 
will  be  found  in  the  Association  Medical  Joitrnal  for  1856. 

"Whatever  the  operation  which  has  been  performed,  care 
should  be  taken  to  secure  all  bleeding  vessels,  and  when 
there  are  bleeding  points  deep  in  the  wound  which  cannot 
thus  be  treated,  the  actual  cautery  should  be  applied  to 
them.     The  dental  artery,  necessarily  divided  in  sawing  the 

c  c 


386  OPERATIONS   ON   THE   LOWER  JAW. 

jaw,  is  sometimes  troublesome  if  its  mouth  is  not  touched 
with  the  cautery,  or  the  dental  canal  plugged  with  a  small 
piece  of  wood.  The  incision  in  the  skin  should  be  carefully 
adjusted  with  fine  wire  sutures,  and  the  lip  brought  together 
with  hare-lip  pins  and  a  twisted  suture^  a  fine  silk  suture 
being  put  in  the  red  mucous-membrane.  Care  must  be 
taken  to  provide  for  the  drainage  of  the  wound  by  leaving 
an  opening  at  the  most  dependent  part,  into  which  a  drain- 
age tube  may  be  put,  and  if  necessary  a  light  bandage  may 
be  applied  to  support  the  parts.  At  the  time  of  the  ojDcra- 
tion  the  wound  may  be  thoroughly  sponged  out  with  a 
solution  of  chloride  of  zinc  (gr.  40  ad  5j),  or  better,  the 
whole  of  the  wound  may  be  thoroughly  sprinkled  with 
iodoform,  which  has  a  most  marked  antiseptic  effect. 

The  after-treatment  consists  in  supporting  the  patient's 
strength  by  administering  fluid  nourishment  with  a  feeder 
or  tube  and  bottle,  and  careful  washing  out  of  the  mouth 
with  detergent  washes,  so  as  to  keep  it  clean  and  healthy 
during  the  process  of  healing;  and  when  the  effects  of  the 
iodoform  have  worn  off,  nothing  is  more  effective  as  an  anti- 
septic than  the  Glycerinum  acidi  carbolici  freely  applied 
with  a  camel's-hair  brush. 

Operations  on  the  lower  jaw  are  quite  of  modern  date. 
Anthony  White,  of  the  Westminster  Hospital,  appears  to 
have  been  the  first  surgeon  who  removed  a  portion  of  the 
lower  jaw  (1804).  He  was  followed  by  Dupuytren  (1812), 
Mott  and  Grafe  (1821),  and  Sir  P.  Crampton  in  1824. 
Cusack's  celebrated  cases  of  disarticulation  occurred  imme- 
diately afterwards,  and  the  operation  became  an  established 
one.  The  names  of  Liston,  Syme,  and  Fergusson  have  been 
prominent  in  connection  with  the  operation  in  this  country, 
whilst  abroad  Lisfranc,  Lallemand,  Maisonneuve,  Gensoul, 
and  other  eminent  men,  have  given  it  their  support. 

It  has  been  already  noticed  how  little  deformity  often 
results  from  the  removal  of  portions  of  the  lower  jaw.  Al- 
though the  bone  is  never  reproduced,  a  development  of  firm 
fibrous  tissue  takes  its  place,  which  affords  support  to  arti- 
ficial teeth,  and  to  which  the  muscles  gain  a  firm  attach- 


ADAPTATION    OF    ARTIFICIAL    TEETH.  387 

ment.  In  February,  1855,  Mr.  Spence,  of  Edinburgh,  brought 
before  the  Medico- Chirurgical  Society  of  Edinburgh  a  pre- 
paration illUvStrating  this  point  in  a  marked  manner.  Eighteen 
years  before  the  patient's  death.  Sir  William  Fergusson  had 
removed  the  greater  part  of  the  right  side  of  the  lower  jaw. 
Five  years  later  Mr.  Spence  had  removed  the  left  side  of 
the  jaw  from  within  half  an  inch  of  the  symphysis  to  the 
articulation,  and  the  condition  found  at  death,  thirteen  years 
after,  is  thus  described  {Edinhurgh  Medical  Journal,  April, 
1855)  : — "A  dense  fibrous  texture  connected  the  small  portion 
of  the  ascending  ramus  of  the  right  side  with  the  remaining 
portion  near  the  symphysis^  whilst  on  the  left  side  a  similar 
texture  occupied  the  place  of  the  disarticulated  bone,  on  both 
sides  affording  firm  attachments  to  the  masseters  and  other 
muscles,  so  that  the  patient  during  life  had  considerable  use 
of  the  mouth." 

The  tendency  of  the  muscles  to  force  the  remaining  portion 
of  the  jaw  out  of  place  has  been  already  referred  to.  In 
cases  in  which  the  central  portion  of  the  jaw  has  been 
removed,  the  force  of  the  muscles  on  both  sides  being  equally 
exerted,  the  rami  of  the  jaw  become  closely  approximated, 
and  are  united  by  very  firm  fibrous  tissue.  This,  of  course, 
gives  a  peculiar  narrowness  to  the  lower  part  of  the  face, 
which  is  fortunately  concealed  in  men  by  wearing  a  beard. 

The  supplying  of  artificial  teeth  to  a  patient  who  has 
undergone  removal  of  a  portion  of  the  lower  jaw  will  tax 
the  ingenuity  of  the  dentist  considerably,  for  when  the 
muscles  have  forced  the  remaining  portion  out  of  position, 
it  becomes  necessary  to  employ  means  to  bring  the  parts 
into  their  normal  relation  so  as  to  obtain  a  proper  "  bite." 
The  vulcanite  rubber  forms  a  most  useful  base  for  the  arti- 
ficial teeth,  and  if  firmly  attached  to  the  remaining  portion 
of  jaw  it  moves  very  satisfactorily  with  it,  lying  in  the 
hollow  of  the  cheek  and  resting  upon  the  dense  fibrous 
tissue  of  the  cicatrix. 


C  C  3 


388 


CHAPTER  XXVI. 


CLOSUEE    OF    THE    JAWS. 


Spasmodic  Closure  of  the  Jaws,  which  may  be  of  several 
weeks^  duration,  is  ahnost  invariably  connected  with  the 
eruption  of  the  wisdom  teeth  of  the  lower  jaw.  Owing  to 
want  of  room  between  the  second  molar  and  the  ramus  of 
the  jaw,  or  owing  to  some  malposition  of  the  tooth  itself, 
the  wisdom  tooth  is  unable  to  assume  its  normal  position, 
and  by  the  pressure  which  it  exerts  on  the  neighbouring 
structures,  sets  up  irritation,  which  induces  a  state  of  tonic 
spasm  of  the  masseter  and  internal  pterygoid  muscles.  This 
fact  has  long  been  known  to  dental  surgeons,  and  is  espe- 
cially alluded  to  by  Mr.  Salter  in  his  essay  on  "  Surgical 
Diseases  connected  with  the  Teeth"  (Si/stem  of  Surgery, 
vol.  ii.). 

The  accompanying  engraving  (fig.  181),  for  which  T  am 
indebted  to  Mr.  Felix  Weiss,  shows  the   condition   of  parts 

Fig.  181. 


found  by  him  in  a  gentleman  aged  forty-three,  who  suffered 
long  and  severely  from  pain  and  spasmodic   closure   of  the 


CLOSURE   OF   THE   JAWS.  389 

jaws,  due  to  the  irritation  caused  by  the  wisdom  tootli  lying 
imbedded  horizontally  in  the  alveolus,  and  pressing  against 
the  fang  of  the  second  molar.  It  was  only  after  the  extrac- 
tion of  tlie  second  molar  that  the  wisdom  tooth  was  found 
and  removed,  with  complete  relief  of  the  symptoms  {Trans. 
Odontological  Society,  1876). 

In  a  discussion  which  took  place  at  the  Odontological 
Society,  in  May,  1861,  and  is  reported  in  the  British 
Journal  of  Dental  Science,  of  the  same  month,  Mr.  Tomes 
mentioned  a  case  of  retarded  eruption  of  the  wisdom  tooth 
with  closure  of  the  jaws,  which  had  been  allowed  to  go 
unrelieved  for  more  than  two  years,  and  was  immediately 
cured  by  the  removal  of  the  second  molars,  so  as  to  allow 
the  wisdom  teeth  to  assume  their  proper  position.  Mr. 
Coleman,  Mr.  Mummery,  and  Mr.  Ibbetson  narrated  on 
the  same  occasion  very  similar  cases  treated  in  the  same 
manner ;  and  Mr.  Drew  mentioned  a  case  in  which  extrac- 
tion of  the  half-cut  wisdom  tooth  itself  gave  immediate 
relief. 

The  majority  of  these  cases  occur  about  the  age  of 
twenty,  when  the  eruption  of  the  wisdom  tooth  is  to  be  ex- 
pected, and  the  diagnosis  is  readily  made.  The  treatment 
is  obvious.  The  mouth  must  be  opened  by  a  screw  gag,  or 
by  a  spu'al  screw  wedge  of  boxwood,  under  chloroform,  and 
either  room  must  be  made  for  the  wisdom  tooth  by  extracting 
the  second  molar,  or,  if  it  can  be  reached,  the  wisdom  tooth 
itself  may  be  removed. 

The  impeded  eruption  of  wisdom  teeth  gives  rise  to 
various  and  apparently  anomalous  symptoms,  which  are  often 
not  traced  to  their  true  source,  such  as  persistent  neuralgia, 
not  always  referred  to  the  part  involved  ;  but  the  most 
serious  result  is  the  formation  of  extensive  abscesses,  which 
burrow  extensively  about  the  angle  of  the  jaw  and  cheek, 
leading  to  great  scarring  and  permanent  deformity.  In  a 
young  lady,  seen  by  me  in  consultation  some  months  back, 
the  mischief  resulting  from  an  impacted  wisdom  tooth  was 
sufficient  to  put  her  life  in  some  jeopardy,  and  has  left  her 
face  permanently  scarred  by  extensive  abscesses. 


390  CLOSURE   OF   THE   JAWS. 

Permanent  Closure  of  the  Jaws. — Cases  of  permanent 
closure  of  the  jaw  from  cicatrices  within  the  mouth,  &c., 
are  not  of  very  rare  occurrence ;  but  their  description  and 
treatment  seem  to  have  been  very  generally  neglected  by 
modern  English  authors.  Samuel  Cooper,  in  the  last  edition 
of  his  "  Surgical  Dictionary"  which  he  revised,  merely  refers 
to  a  case  treated  by  Valentine  Mott,  who,  in  1831,  operated 
on  a  case  of  sloughing  of  the  cheek,  with  subsequent  closure 
of  the  jaws,  by  transplanting  a  piece  of  skin  (see  American 
Journal  of  Medical  Science  for  Nov.  1831) ;  but  he  enters  no 
farther  into  the  treatment.  In  the  new  edition  of  "  Cooper's 
Dictionary,  1861,  vol,  i.,  the  only  passage  I  can  find,  bearing 
on  the  question,  is  tlie  following,  under  the  head  of  "  Cica- 
trization :" — 

"  In  the  mouth,  after  sloughing  of  the  cheek  and  gums 
from  profuse  salivation,  the  cicatiized  surface  is  so  rigid  as 
scarcely  to  allow  of  the  separation  of  the  teeth,  but  it  be- 
comes more  pliant  in  time."  This  latter  statement,  however, 
is  not  borne  out  by  general  experience. 

Sir  William  Fergusson,  in  the  fourth  edition  of  his  "  Prac- 
tical Surgery,"  p.  603,  says  : — 

"  The  lower  jaw  occasionally  becomes  so  closely  bound  to 
the  upper,  that  the  teeth  cannot  be  sufficiently  separated  to 
admit  of  solid  food.  This  condition  may  arise  from  inflam- 
mation and  adhesion  of  the  gums,  more  especially  after 
necrosis  of  the  alveolar  processes ;  sometimes  it  is  the  result 
of  chronic  contraction  of  a  muscle ;  occasionally  it  has  been 
accompanied  with  ankylosis,  both  here  and  in  other  joints, 
of  which  there  is  a  remarkable  specimen  in  the  possession  of 
M.  Dubreuil,  of  Montpelier,  in  which,  however,  a  similar 
condition  was  not  present  in  any  other  part  of  the  same 
skeleton ;  and  in  certain  examples  it  is  difficult  to  say  what 
is  the  cause.  Some  years  ago  I  had  a  patient  with  the  mouth 
thus  contracted,  and  in  whom  there  was  a  portion  of  the 
lower  jaw  in  a  state  of  caries :  the  disease  was  not  in  such 
a  condition  that  I  could,  with  propriety,  attempt  its  entire 
removal.  A  portion  of  bone,  however,  was  excised,  but  little 
benefit  resulted,  and  what  there  was  might  probably  be  attri- 


CLOSURE   OF   THE   JAWS.  391 

buted  more  to  the  use  of  a  screw-dilator  than  to  the  partial 
removal  of  what  I  considered  a  source  of  irritation.  Mott 
has  succeeded,  in  two  instances,  in  relieving  such  permanent 
adstrictions ;  and  in  the  first  volume  of  the  Frovincial 
Medical  and  Surgical  Journal  there  is  a  case  recorded 
wherein  I  was  fortunate  enough  to  produce  a  similar  effect, 
by  dividing  the  masseter  on  one  side  with  a  narrow  knife, 
passed  from  the  mouth  between  that  muscle  and  the  skin. 
If  ankylosis  be  the  cause  of  closure,  it  is  doubtful  if  the  sur- 
geon would  be  justified  in  interfering.  In  the  course  of  my 
experience  I  have  seen  many  instances  of  the  kind  above 
referred  to,  but  feel  bound  to  state  that  most  of  my  attempts 
at  improvement  have  utterly  failed." 

By  far  the  most  complete  account  of  this  affection  is 
given  by  Dr.  Samuel  G-ross,  of  Philadelphia^  in  his  large  work 
on  surgery,  from  which  I  take  the  following  quotation  :— 

"Ankylosis,  or  Immobility  of  the  Jaiu. — Tliis  distressing 
affection,  which  may  be  produced  in  a  variety  of  ways,  may 
exist  in  such  a  degree  as  to  render  the  patient  entirely  unable 
to  open  his  mouth,  or  to  masticate  his  food. 

^'  The  most  common  cause,  according  to  my  observation, 
is  profuse  ptyalism,  followed  by  gangrene  of  the  cheeks^  lips, 
and  jaw,  and  the  formation  of  firm,  dense,  unyielding,  ino- 
dular  tissue,  by  which  the  lower  jaw  is  closely  and  tightly 
pressed  against  the  upper.  Such  an  occurrence  used  to  be 
extremely  frequent  in  our  south-western  States  during  the 
prevalence  of  the  calomel  practice,  as  it  was  termed,  but  is 
now,  fortunately,  rapidly  diminishing. 

"  Children  of  a  delicate,  strumous  constitution,  worn  out 
by  the  conjoint  influence  of  mercury  and  scarlatina,  measles, 
or  typhoid  fever,  are  its  most  common  victims ;  but  I  have 
also  seen  many  cases  of  it  in  adults  and  elderly  subjects. 
In  the  worst  cases  there  is  always  extensive  perforation  of 
the  cheeks,  permitting  a  constant  escape  of  the  saliva,  and 
inducing  the  most  disgusting  disfigurement. 

"  Secondly,  the  affection  may  depend  upon  ankylosis  of 
the  temporo-maxillary  joints,  in  consequence  of  injury,  as  a 
severe  sprain  or  concussion,  or  arthritic  inflammation,  lead- 


392  CLOSURE   OF   THE   JAWS. 

ing  to  a  deposition  of  plastic  matter,  and  the  conversion  of 
this  substance  into  celkilo-fibrous,  cartilaginous,  or  osseous 
tissue.  I  have  met  with  quite  a  number  of  such  cases, 
several  in  very  young  subjects. 

"  Thirdly,  the  immobility  is  occasioned  by  a  kind  of 
osseous  bridge,  extending  from  the  lower  to  the  upper  jaw, 
or  from  the  lower  jaw  to  the  temporal  bone;  such  an 
occurrence,  however,  is  not  common,  and  is  chiefly  met 
with  in  persons  who  have  suffered  from  chronic  articular 
arthritis. 

"Finally,  immobility  of  the  jaw  may  be  caused  by  the 
pressure  of  a  neighbouring  tumour^  especially  if  it  occupies 
the  parotid  region,  so  as  to  make  a  direct  impression  upon 
the  temporo-maxillary  joint. 

"However  induced,  the  effect  is  not  only  inconvenient, 
seriously  interfering  with  mastication  and  articulation,  but 
it  is  often  followed,  esjDccially  if  it  occur  early  in  life,  by  a 
stunted  development  of  the  jaw,  exhibiting  itself  in  marked 
shortening  of  the  chin,  and  in  an  oblique  direction  of  the 
front  teeth. 

"  When  comjDlicated  wdth  perforation  of  the  cheek  and 
destruction  of  the  lips,  the  patient  has  little  or  no  control 
over  his  saliva,  and  is  so  terribly  deformed  as  to  render  him 
an  object  at  once  of  the  deepest  disgust  and  the  warmest 
sympathy. 

"  The  treatment  of  this  affection  must  depend  upon  the 
nature  and  situation  of  the  exciting  cause.  When  the 
difficulty  is  in  the  joint,  occasioned  by  the  formation  of 
cellulo-fibrous  adhesions,  the  only  thing  that  can  be  done  is 
to  break  up  the  adhesions,  upon  the  same  principle  as  in 
ankylosis  of  any  other  joints.  Por  that  purpose — the  patient 
being  thoroughly  under  the  influence  of  chloroform — the  jaw 
is  forcibly  depressed,  either  by  a  Avedge  made  of  cedar-wood, 
or  by  an  instrument  constructed  on  the  lever-and-screw 
principle,  and  figured  by  Scultetus  in  his  '  Armamentarium 
Chirurgicum.' 

"  When  the  immobility  depends  upon  the  presence  of 
inodular  tissue,  the  proper  remedy  is  excision  of  the  ofFeuding 


CLOSURE    OF   THE   JAWS.  393 

substaucu — an  operation  which  is  both  tedious,  painful,  and 
bloody,  and,  unfortunately,  not  often  followed  by  any  but 
the  most  transient  relief,  owing  to  the  tendency  in  the  parts 
to  reproduce  the  adhesions,  however  carefully  and  thoroughly 
they  may  have  been  removed.  There  is  the  same  remark- 
able disposition  in  these  cases  to  the  contraction  and  re- 
generation of  the  inodular  tissue,  as  in  the  case  of  burns 
and  scalds. 

"During  my  residence  in  Kentucky  I  had  a  large  share 
of  such  cases ;  and,  although  I  never  failed  to  make  the 
most  thorough  work — not  unfrequently  repeating  the  opera- 
tion several  times  at  intervals  of  a  few  months — it  is  my 
duty  to  state  that  few  of  them  were  permanently  relieved. 
After  the  excision  is  effected,  the  patient  must  make  constant 
use  of  the  wedge,  wearing  it  for  months  and  years,  so  as  to 
counteract  the  tendency  to  reclosure. 

"  Immobility  of  the  jaw,  caused  by  the  formation  of  an 
osseous  bridge,  might  possibly  be  remedied  by  the  removal 
of  the  adventitious  substance  by  means  of  the  saw  and  pliers. 
The  great  difficulty,  however^  in  such  an  event,  is  the 
obscurity  of  the  diagnosis." 

1  must  now  refer  to  an  essay  by  Dr.  Frederic  Esmarch, 
Professor  of  Surgery  in  the  University  of  Iviel,  on  "  The 
Treatment  of  Closure  of  the  Jaws  from  Cicatrices,""^  in 
which  he  investigates  the  pathology  of  the  affection,  and 
describes  an  operation  for  its  relief  by  the  formation  of  an 
artificial  joint  in  the  lower  jaw — an  operation  which  has 
given  most  satisfactory  results  in  cases  under  my  own 
treatment. 

Professor  Esmarch  says  : 

"  Injuries  to  the  mucous  membrane  of  the  cheek  damage 
the  mobility  of  the  lower  jaw  in  a  greater  or  lesser  degree 
by  their  cicatrisation,  as  is  well  known. 

"  The  cause  of  this  ankylosis  of  the  lower  jaw  is  often 
thought  to  be  a  oTowino;  touether  of  the  inner  surface  of  the 
cheek  with  the  bones  or  gums ;  this  is  not  a  correct  view, 

*  "Die  Behaudliing  der  narbigen  Kieferklemme  durch  Bilduug  eines 
kiinstliclien  Gelenkes  urn  Unterkiefer."     Kiel,  1860. 


394  CLOSURE   OF   THE  JAWS. 

however,  and  has,  in  many  cases,  led  to  improper  treatment. 
In  order  to  clear  up  this  error  it  is  necessary  to  examine  the 
conditions  which,  in  health,  make  movements  of  the  lower 
jaw  within  the  mouth  possible.  The  cavity  of  the  mouth  is 
divided  by  the  alveoli  and  teeth  into  an  inner  and  outer 
space ;  the  latter  is  closed  in  front  by  the  cheeks  and  lips, 
which  form  an  elastic  dilatable  sac  ;  within  this  the  rows  of 
teeth  can  be  separated  from  each  other,  even  with  the  lips 
shut,  and  much  further  when  the  mouth  is  opened.  The 
inner  surface  of  this  sac  is  covered  by  a  mucous  membrane 
which  is  also  very  dilatable  and  elastic,  and  which  forms  a 
duplicature  at  the  upper  and  lower  boundaries  of  the  outer 
cavity  of  the  mouth,  where  it  is  reflected  on  to  the  outer 
surface  of  the  bone,  and  ends  on  the  edges  of  the  alveolus 
as  gum.  This  membrane  is  so  elastic  that  when  the  mouth 
is  open  to  its  widest  extent  it  is  still  by  no  means  put  on 
the  stretch  ;  whilst,  when  the  mouth  is  closed,  it  presents 
no  folds. 

"  It  is  clear  that  as  soon  as  this  dilatable  sac  shrinks 
together,  loses  its  elasticity,  or  is  replaced  by  a  rigid  sub- 
stance, the  mobility  of  the  jaw  must  either  be  injured  or 
entirely  cease.  This  happens  most  frequently  through  the 
formation  of  cicatrices  which  follow  ulceration  or  sloughing 
of  the  mucous  membrane  of  the  mouth,  as  from  mercurial 
stomatitis  or  noma. 

"  The  occurrence  of  what  we  call  secondary  cicatrix- 
atrophy,  or  cicatrix-contraction,  is  sufficiently  well  known. 
As  soon  as  the  cure  commences,  the  movable  parts  of  the 
neighbourhood,  so  far  as  they  can  be,  are  drawn  by  the 
shrinking  of  the  newly  formed  tissue  towards  the  cicatrising 
spot;  slowly,  it  is  true,  but  with  almost  irresistible 
power. 

"  If  there  are  no  parts  in  the  neighbourhood  which  can  be 
drawn  together  to  repair  the  loss  of  substance,  there  neces- 
sarily follows  a  cicatrisation  of  the  surface ;  but  the  cicatrix 
remains  thin,  tender,  and  stretched  to  a  great  extent  for 
some  time  at  least  after  its  formation ;  it  is  only  after  it  has 
existed  for  a  long  time  tliat  it  assumes  a  more  ductile  con- 


CLOSUEE   OF   THE  JAWS.  395 

dition,  so  as  to  become  something  more  like  the  natural  skin 
or  mucous  membrane. 

"  If,  therefore,  the  mucous  membrane  of  the  cheek  be  com- 
pletely destroyed  from  one  alveolus  to  the  other,  on  both,  or 
merely  on  one  side,  the  resulting  cicatrix  must  necessarily 
tend  to  press  the  jaws  more  and  more  closely  against  one 
another,  the  depressor  muscles  of  the  lower  jaw  being  quite 
incapable,  as  experience  has  shown,  of  preventing  the  con- 
traction of  the  cicatrix.  When  cicatrisation  is  complete,  the 
elastic  ductile  mucous  sac  of  the  cheek  is  found  to  have  dis- 
appeared, and  instead  of  it  the  cicatrix  tissue  stretches  so 
tightly  from  one  alveolar  edge  to  the  other,  that  it  is  scarcely 
possible  to  put  the  finger  between  it  and  the  rows  of  teeth ; 
and  the  teeth  themselves  can  be  separated  only  a  little,  if  at 
all,  or  only  shifted  from  side  to  side  very  slightly. 

"Just  the  same  immobility  of  the  lower  jaw  follows 
cicatrisation  after  sloughing  involving  the  whole  thickness 
of  the  cheek,  although  here  the  opening  of  the  mouth  is 
widened  as  far  as  the  anterior  edge  of  the  masseter  muscle, 
or  still  farther ;  and  in  this  case,  too,  the  cheek  sac  is  entirely 
destroyed.  In  these  cases  it  is  the  quasi  lip  or  posterior 
margin  of  the  gap  which  stretches  tightly  from  one  jaw  to 
the  other.  If,  in  such  cases,  one  is  successful  in  covering 
the  loss  of  substance  by  dividing  the  skin,  or  by  transplanta- 
tion of  a  flap,  the  cicatrisation  of  the  inner  surface  of  the 
flap  (being  uncovered  by  mucous  membrane)  necessarily  has 
the  effect  of  increasing  the  immobility  of  the  lower  jaw. 

"  As  far  as  is  known  there  are  few  or  no  means  available 
to  check  the  shrinking  of  cicatrices.  It  is  one  of  Dieffenbach's 
great  services  to  surgery  that  he  gave  this  theory  its  full 
value ;  it  was  he  who  first  taught  us  to  place  a  proper  value 
upon  this  action  of  Nature,  and  showed  how  to  make  it 
available  for  operative  proceedures  under  certain  circum- 
stances. Thus,  he  first  taught  how  to  cm-e  the  closure  of 
the  mouth  by  covering  the  margin  with  mucous  membrane ; 
to  form  eyelids  which  do  not  adhere  to  the  globe  or  roll 
inwards  after  cicatrisation  ;  and  many  other  methods  which 
we  now  consider  self-evident  in  plastic  surgery. 


396  CLOSURE   OF   THE   JAWS. 

"Also,  for  the  treatment  of  the  worst  cases  of  cicatrised 
contracted  jaw,  DiefFenbach  has  given  the  most  rational 
advice  when  he  suggests,  after  the  separation  of  the  cicatrix 
from  the  bones,  to  lay  over  the  surface  of  the  wound  a  sound 
flap  of  mucous  membrane.  Unfortunately,  in  most  cases, 
this  cannot  be  done,  because,  just  in  the  neighbourhood  of 
the  cicatrix,  it  is  impossible  to  find  more  healthy  mucous 
membrane.  Instead  of  the  mucous  membrane  one  can 
undoubtedly  do  as  Jaesche  did  {Med.  Zcitumj  Etisslcmds,  xxvii. 
1858),  viz.,  make  use  of  a  flap  of  skin  for  a  lining ;  still  it  is 
difficult  in  many  cases  to  get  such  a  flap  from  the  immediate 
neighbourhood.  I  would  not  hesitate,  however,  in  desperate 
cases — as,  for  instance,  where  there  is  a  great  deficiency  on 
both  sides — to  take  a  flap  from  the  skin  of  the  arm. 

"  All  the  hitherto  received  methods,  such  as  the  freeing 
or  cutting  through  of  the  cicatrix  from  the  mouth — the 
separation  of  the  M-hole  cheek,  in  order  to  accomplish  this 
perfectly — the  extirpation  of  the  mass  of  cicatrix — the  ap- 
plication of  mechanical  apparatus  in  order  to  drag  the  jaws 
asunder  by  degrees,  &c.  &c.,  can  only  be  of  avail  in  those 
cases  where,  in  some  angle  or  other,  there  is  found  a  remnant 
of  mucous  membrane.  If  one  succeeds  after  separation  of 
the  cicatrix,  in  preventing,  by  the  aiDplication  of  mechanical 
means  for  a  long  time,  the  cicatrisation  in  the  undesirable 
direction,  the  contraction  will  take  place  in  another  direction, 
and  by  degTees  will  drag  the  remnant  of  mucous  membrane 
up  to  the  skin.  In  every  case  it  takes  years  before  such 
methods  can  be  i)roperly  estimated  ;  for,  as  far  as  is  known, 
the  secondary  shrinking  of  a  cicatrix  takes  place  very  late, 
even  after  complete  or  sufficient  healing  over  has  occurred. 
Putting  aside  the  more  favourable  cases,  there  still  remains 
a  number  of  patients  of  this  kind,  in  whom  the  usual  methods 
produce  no  lasting  cure,  just  because  there  is  no  more  old 
mucous  membrane  left;  and  for  these  cases  I  recommend 
the  formation  of  an  artificial  joint  in  front  of  the  contraction, 
in  order  to  give,  at  least,  tlie  other  half  of  the  jaw  some, 
although  a  limited,  motion,  and  so  to  lessen  considerably  the 
sufferings  of  these  unfortunate  patients. 


CLOSURE   OF   THE   JAWS.  397 

"  The  formation  of  an  artificial  joint  in  the  ramus  of  the 
jaw  has  already  been  recommended  and  tried  by  Dieffenbach 
('  Operative  Chirurgie,'  i.  435),  but  hehind  the  contraction, 
and  naturally  without  any  good  result,  since  the  impediment 
to  motion  lies  more  forward,  and  thus  is  not  removed.  Von 
Briins  has  also  operated  in  this  manner  without  success,'^ 

This  proposal  of  Professor  Esmarch  to  form  a  false  joint 
in  front  of  the  cicatrix  was  suggested  to  him  by  a  case  which 
came  under  his  care  in  1854,  in  which  considerable  destruc- 
tion of  the  cheek  and  contraction  of  the  cicatrix  had  oc- 
curred, together  with  immobility  of  the  lower  jaw  and 
necrosis  of  a  portion  of  it.  The  necrosed  portion  was  for- 
tunately in  front  of  the  cicatrix.  The  bone  having  been 
removed,  it  was  found  that  mobility  was  restored,  and  a 
useful  amount  of  movement  obtained.  Professor  Esmarch 
therefore  suggested,  at  the  Congress  of  Gottingen,  in  1855, 
the  removal  of  a  piece  of  bone  in  cases  of  contracted  cicatrix; 
but  did  not  happen  to  meet  with  a  case  suitable  for  the 
operation  until  after  it  had  been  successfully  performed  by 
Dr.  Wilms,  of  Berlin,  in  1858^  shortly  after  which  he  himself 
operated  upon  a  case  at  Kiel,  and  with  the  best  results.  The 
operation  was  subsequently  performed  by  Dittl,  of  Vienna 
{Oest,  ZeitscIiHft  fur  iprahtische  Heilkunde,  vol.  v.  p.  43, 
Vienna,  1859)  ;  and  by  Wagner,  of  Konigsberg  (Annali  di 
Medicina  di  Koenigsberg,  vol.  ii.  p.  100,  1859). 

Shortly  after  this  proposal  of  Esmarch,  it  would  appear 
that  Professor  Ptizzoli,  of  Bologna,  quite  independently  con- 
ceived a  somewhat  similar  idea,  but  modified  the  proceeding 
by  merely  cutting  through  the  jaw,  without  removing  any 
portion  of  bone.  He  operated  in  this  way  first  in  1857^  and 
subsequently  had  three  other  successful  cases.  In  Pdzzoli's 
cases  no  external  incision  appears  to  have  been  made,  but 
the  section  was  accomplished  from  the  mouth  with  powerful 
forceps.  This  proceeding  has  been  followed  by  Professor 
Esterle,  from  whose  essay  in  the  Annali  Universcdi  di 
Medicina  (Omodei,  vol.  clxxvi.),  I  have  extracted  these 
particulars. 

Esmarch's  operation  appears  to  me  to  possess  a  decided 


398  CLOSURE   OF   THE   JAWS. 

advantage  over  that  of  Eizzoli,  in  the  fact  that  a  piece  of 
bone  is  removed,  by  which  the  formation  of  a  false  joint  is 
facilitated,  as  we  know  by  experience  in  cases  of  resection  of  ■ 
the  elbow,  &c. ;  and  the  external  incision  can  never  be  a 
matter  of  any  importance,  whilst  it  admits  of  the  application 
of  the  saw,  and  so  avoids  risk  of  splintering  the  bone. 

Mr.  Mitchell  Henry  was,  I  believe,  the  first  surgeon  to 
put  Esmarch's  operation  into  practice  in  this  country,  he 
having  performed  it  a  few  weeks  before  myself.  The  patient 
was  a  female,  on  whom  a  variety  of  operations  had  been 
performed  (among  others,  division  of  the  masseter),  and 
whom  I  had  had  under  my  own  care  at  the  St.  George's  and 
St.  James's  Dispensary,  two  years  before,  when  I  divided 
the  cicatrices  freely  and  screwed  the  mouth  open,  but  with- 
out permanent  benefit.  Mr.  Henry  employed  the  chain 
saw,  and  removed  about  half  an  inch  of  bone.  The  patient, 
unfortunately,  sank  a  few  days  afterwards,  apparently  from 
pyaemia  and  exhaustion.  In  my  own  cases  I  used  an  ordi- 
nary narrow  saw,  in  preference  to  the  chain,  and  was  enabled 
to  remove  sufficient  bone  to  give  free  movement,  through  a 
small  incision  along  the  edge  of  the  jaw. 

The  subject  of  the  contraction  of  cicatrices  in  the  mouth, 
and  their  treatment,  though  it  has  attracted  little  notice 
among  British  authors,  in  Paris,  on  the  contrary,  has 
excited  much  attention,  and  has  furnished  the  topic  of 
frequent  discussions  at  the  Societ(3  de  Chirurgie.  Since  the 
date  of  the  publication  of  a  paper  upon  the  subject  by 
M.  Verneuil  {Archives  G^nerales,  1860),  several  operations 
have  been  performed  by  French  surgeons,  but  apparently 
with  but  little  success,  since  in  cases  operated  on  both  by 
the  method  of  Esmarch  and  of  Eizzoli  reunion  of  the 
divided  jaw  has  taken  place. 

Thus,  on  the  4th  of  February,  1863,  M.  Boinet  brought 
before  the  Society  a  little  girl  on  whom  he  had  previously 
performed  what  he  terms  Esmarch's  operation  (but  which 
appears  to  have  consisted  in  the  simple  division  of  tlie  jaw, 
recommended  by  Eizzoli,  and  not  the  removal  of  a  wedge 
of  bone,  as  originally  proposed  by  Esmarch),  and  in  whom 


CLOSUKE    OF   THE   JAWS.  399 

the  bone  had  reunited.  M.  Deguise  thereupon  quoted  a 
case  in  which  he  had  removed  a  centimetre  and  a  half  of 
bone  with  the  same  unsatisfactory  result,  and  expressed  a 
doubt  whether  a  single  successful  case  could  be  produced. 
On  the  11th  of  February,  1863,  M.  Deguise  brought  the  case 
he  had  alluded  to  before  the  Society,  and  showed  that  the 
failure  "  depended  upon  the  formation  of  an  osseous  callus 
at  the  level  of  the  resected  portion."  At  the  same  meeting 
M.  Bauchet  showed  a  young  Syrian  girl  in  whom  contrac- 
tion of  the  left  side  had  taken  place,  together  with  a  loss  of 
substance  of  the  cheek  and  commissure  of  the  lips,  equalling 
a  five-franc  piece  in  size.  In  this  case  a  centimetre  and  a 
half  of  the  jaw  was  removed  ;  and  though  extensive  suppu- 
ration and  necrosis  of  the  jaw  ensued,  the  girl  made  a  good 
recovery,  and  at  that  date  (February  4)  a  very  satisfactory 
amount  of  movement  and  power  of  mastication  had  been 
obtained. 

On  the  29th  of  July,  1863,  M.  Verneuil  communicated  to 
the  Societe  de  Chirurgie  the  histories  of  several  cases  ope- 
rated upon  by  M.  Eizzoli  himself,  the  results  of  which  were 
most  satisfactory.  In  the  first  the  operation  (simple  division 
of  the  jaw  from  within  the  mouth)  was  performed  in  1857, 
and  after  six  years  the  boy  was  able  to  eat  solid  food  most 
satisfactorily ;  the  second  case,  operated  upon  in  the  same 
year,  was  equally  good.  In  the  third  case,  operated  upon  in 
1858,  the  mouth  could  not  be  widely  oj^ened,  and  the  child 
had  some  difficulty  in  speaking.  The  fourth  case,  operated 
upon  in  1860,  was  most  satisfactory.  M.  Verneuil  also 
mentioned  a  fatal  case  which  occurred  in  M.  Eizzoli's  prac- 
tice, and  alluded  to  my  paper  in  the  Dublin  Quarterly  Journal 
of  May,  1863. 

It  would  appear  that  M.  Eizzoli  had  adopted  the  plan  of 
inserting  a  foreign  body,  such  as  a  piece  of  gutta-percha, 
between  the  cut  surfaces  of  bone,  with  the  view  of  preventing 
their  reunion,  and  the  possibility  of  doing  this  was  roundly 
denied  by  one  of  the  speakers  at  the  Soci^t^  de  Chirurgie. 
There  appears  to  me,  however,  to  be  no  difficulty  in  effecting 
this,  provided  the  section  be  made  from  within  the  mouth 


400  CLOSURE   OF   THE   JAWS. 

and  without  external  incision,  as  proposed  by  M.  Eizzoli,  but 
I  cannot  speak  with  certainty,  ha^'ing■  no  experience  of  his 
operation. 

One  observation  of  M.  Yerneuil's  is,  I  think,  worthy  of 
special  notice — viz.,  that  all  Pdzzoli's  successful  cases  have 
been  examples  of  contraction  within  the  mouth  Mdthout  loss 
of  substance  of  the  cheek,  whereas  the  unsuccessful  cases  of 
the  operation  which  have  occurred  in  Paris  had  suffered 
considerable  damage  in  the  soft  tissues ;  and  he  suggests 
that  in  these  cases  Esmarch's  operation  may  be  more  properly 
applicable.  In  one  of  my  cases  the  loss  of  substance  in 
the  cheek  had  been  replaced  by  a  dense  cicatrix,  which  it 
would  have  been  unwise  to  interfere  with  from  within  the 
month,  and  at  the  same  time,  owing  to  its  firm  contraction, 
it  would  have  been  impossible  to  have  performed  Piizzoli's 
operation  in  the  way  he  recommends — viz.,  without  any 
external  incision.  1  therefore  resorted  to  Esmarch's  pro- 
ceeding, M-ith  the  results  of  which  I  have  every  reason  to  be 
satisfied. 

The  first  case  in  wlvich  I  performed  Esmarch's  operation 
was  in  a  boy  aged  fifteen,  who  was  sent  to  me  by  Mr. 
Martin,  of  Portsmouth,  in  1862,  with  complete  closure  of 
the  jaws,  the  result  of  the  contraction  of  cicatrices  within 
the  mouth  following  extensive  necrosis.  The  cicatrices  had 
been  divided,  and  his  mouth  screwed  open  in  1856,  but 
without  permanent  benefit,  and  he  obtained  his  food  by 
rubbing  it  between  his  teeth,  or  by  putting  it  through  an 
aperture  between  the  teeth  on  the  right  side.  The  mouth 
was  firmly  closed,  the  teeth  overlapping ;  there  was  a  cica- 
trix at  the  right  angle  of  the  mouth,  and  a  dense  band  could 
be  felt  within  the  mouth  on  the  same  side.  Fig.  182  shows 
liis  condition  on  admission.  I  made  an  incision  two  inches 
long  upon  the  lower  border  of  the  jaw,  in  front  of  the  right 
masseter,  and  removed  a  wedge  of  bone  measuring  rather 
more  than  a  quarter  of  an  inch  along  the  upper,  and  Imlf  an 
inch  along  the  lower  border.  The  piece  contained  the 
mental  foramen.  The  mouth  could  now  be  freely  opened, 
and  the  boy  was  discharged  at  the  end  of  a  month  able  to 


CLOSURE   OF   THE  JAWS. 


401 


open  his  mouth,  as  seen  in  fig.  183 ;  the  distance  between 
the  teeth  beino'  seven-eighths  of  an  inch, 


Fig.  182. 


Fig.  183. 


The  second  case  in  which  I  operated  in  the  same  manner 
was  complicated  by  the  presence  of  a  dense  cicatrix,  occupy- 
ing nearly  the  whole  of  the  cheek  of  the  affected  side.  The 
angle  of  the  mouth  had  also  given  way  during  a  recent 
attack  of  fever,  and  the  patient  presented  the  unsightly  ap- 
pearance shown  in  fig.  18-i.  The  patient  was  twenty-tlu^ee 
years  old,  and  the  sloughing  and  contraction  occurred  at  the 
age  of  six.  She  was  sent  to  me  by  Mr.  BuUen,  of  the 
Lambeth  Infirmary,  in  January,  1864,  I  made  an  incision 
along  the  border  of  the  jaw,  and,  as  in  the  former  case,  re- 
moved a  wedge  of  bone  measuring  seven-eighths  of  an  inch 
along  its  lower  border.  This  also  contained  the  mental 
foramen.  The  patient's  mouth  could  now  be  opened  to  the 
extent  of  half  an  inch.  I  made  two  subsequent  attempts  to 
remove  the  deformity  of  the  cheek  by  plastic  operations, 
but  only  succeeded  in  restoring  the  commissure  of  the  lips, 
the  vitality  of  the  cicatricial  tissue  being  too  low  to  admit 
of  its  uniting  with  other  tissues.     At  the  time  of  her  dis- 


402 


CLOSURE   OF   THE   JAWS. 


charge  the  commissure  of  the  lip  was  half  an  inch  in 
hreadtli ;  and  with  a  piece  of  black  plaster  over  the  opening 
which  was  left  behind  it,  the  patient  was  very  comfortable. 


Fig.  184. 


Fig.  185. 


rig.  185  shows  her  condition  at  tliis  time  with  the  mouth 
open. 

With  regard  to  the  permanency  of  the  relief  afforded  in 
these  cases,  I  may  mention  that  Barton  B.,  the  boy  on 
whom  I  operated  in  July,  1862,  continued  in  perfect  health, 
and  able  to  take  plenty  of  nourishment,  although  the  move- 
ments of  the  jaw  had  very  decidedly  diminished,  owing 
apparently,  to  contraction  of  the  fibrous  tissues  around  the 
new  joint,  due,  as  the  patient  and  his  mother  believe,  in  the 
first  instance,  to  the  cold  of  the  severe  winter  following  the 
operation,  from  which  he  suffered  considerably. 

In  March,  1865,  I  had  the  boy  up  from  the  country,  and 
found  that  the  space  between  the  left  molar  teeth  had 
diminished  from  seven-eighths  to  one-eighth  of  an  inch,  and 
that  between  the  left  lateral  incisors  from  five-eighths  to 
two-eighths  of  an  incli.  The  movement  was  still  free  enough 
to    show    that    osseous  ankylosis   had  not  taken  place  in 


CLOSURE    OF   THE   JAWS.  403 

the  new  joint ;  but  whether  the  contraction  was  due 
simply  to  changes  at  that  point  or  to  the  contraction  of 
some  band  it  was  impossible  to  determine,  as  the  boy 
positively  refused  all  interference,  either  with  or  without 
chloroform. 

In  this  case,  however,  I  believe  that  I  was  not  sufficiently 
careful  to  make  the  section  of  the  bone  entirely  in  front  of 
the  cicatrices,  a  point  I  bore  in  mind  in  the  second  opera- 
tion. 

The  second  patient,  Ellen  Johnson^  is  in  perfect  health, 
and  has  good  use  of  her  jaw,  I  saw  her  at  Plymouth  in 
August,  1866,  and  have  heard  since  that  she  continues  per- 
fectly well.  She  called  on  me  in  July,  1880,  in  good  health 
and  with  perfect  movement  of  the  joint.  The  opening  in 
the  cheek  remained  the  same. 

Mr.  Bernard,  of  Clifton,  performed  Esmarch's  operation 
with  the  greatest  success,  upon  a  young  man  of  twenty- one, 
in  January,  1865.  The  case  was  one  of  great  destruction 
of  the  cheek  by  sloughing,  and  the  alveoli  of  the  upper  and 
lower  jaw  projected  considerably  through  the  aperture  thus 
left.  Mr.  Bernard  cut  away  the  alveoli,  and  then  removed 
a  wedge  from  the  lower  jaw  in  front  of  the  contraction  with 
the  most  satisfactory  results. 

In  the  Medical  Times  and  Gazette,  1876,  will  be  found 
cases  of  Esmarch's  operation  performed  successfully  at  St. 
Thomas's  Hospital  by  Sir  W.  MacCormac  and  Mr.  Francis 
Mason ;  at  the  Middlesex  Hospital,  by  Mr.  Lawson ;  and  at 
the  Hotel  Dieu,  Paris,  by  M.  Ptichet.  In  1883  I  again  per- 
formed the  operation  in  University  College  Hospital,  on  a 
woman,  aged  thirty- two,  who  was  kicked  by  a  horse  on  the 
right  side  of  the  face  when  eleven  years  of  age,  since  which 
she  had  had  more  or  less  closure  of  the  jaws.  The  teeth 
were  firmly  closed,  the  lower  incisors  being  forced  outwards. 
It  was  clearly  a  case  of  ankylosis  of  the  temporo -maxillary 
articulation,  and  I  should  have  preferred  to  operate  in  that 
region,  but  for  the  patient's  anxiety  to  be  relieved  as  soon 
as  possible  in  order  to  return  to  her  family.  She  recovered 
with  good  use  of  the  jaw, 

P  D  2 


404  CLOSURE   OF   THE   JAWS. 

Ill  connection  with  this  subject,  and  to  show  the  patholo- 
gical result  of  the  proceeding,  I  may  refer  to  the  following 
account  of  the  post-mortem  examination  of  a  case  of 
Esmarch's  operation,  read  before  the  Societe  Imperiale  de 
Cliirurgie,  September  5,  1866. 

M,  Boinet  showed  the  lower  jaw  of  a  girl  who  had  closure 
of  the  jaws  from  cicatrices  resulting  from  cancrum  oris. 
Eizzoli's  operation  had  been  performed  at  the  beginning  of 
1860,  but  failed  at  the  end  of  twelve  months.  In  1863  a 
wedge  was  removed  with  perfect  success.  She  died  of 
phthisis  in  1866. 

"  The  right  ramus  of  the  jaw  is  deformed,  being  shorter 
and  broader  than  on  the  opposite  side.  The  condyle  and  the 
coronoid  process  are  less  separated  and  shorter  than  on  the 
left  side,  and  the  sigmoid  notch  is  shallower.  The  left  teni- 
poro-maxillary  articulation  has  lost  much  of  its  mobility, 
and  the  ligaments  are  shortened.  The  sections  had  been 
made  in  the  middle  of  the  body  of  the  bone,  the  angle  being 
intact.  The  lower  border  of  the  jaw  presents  a  difterence 
in  length  of  IJ  centimetre  between  the  two  sides,  which  cor- 
responds to  the  breadth  of  the  wedge  of  bone  removed  at 
the  operation.  The  osseous  tissue  of  the  ascending  ramus 
appeared  reddened,  the  dental  nerve  was  natural  at  its  entry 
into  the  inferior  dental  foramen.  Between  the  two  portions 
of  the  jaw  there  exists  a  very  complete  false  joint,  which  is 
permanent  three  years  after  the  operation  ;  it  is  very  mobile, 
and  the  parts  which  serve  as  the  hinge  are  fibrous  and 
stretched  so  that  the  middle  portion  of  the  jaw  can  fall ; 
during  life  this  was  suf3&cient  to  allow  easily  the  introduction 
of  the  forefinger  into  the  mouth.  The  fibrous  tissue  which 
unites  the  bones  occupies  the  whole  interval  left  between  the 
bones,  and  extends  for  the  whole  depth  of  the  jaw.  Its 
breadth  appears  to  be  quite  a  demi-centimetre,  and  its 
strength  uniform."  —  Gazette  Hcbdomadaire,  October  12, 
1866. 

In  a  few  cases  of  bilateral  ankylosis  it  has  been  thought 
advisable  to  perforin  Esmarch's  operation  on  both  sides  of 
the  jaw.     Thus  Dr.  Maas,  of  Breslau,  relates  in  the  Archiv 


CLOSURE   OF   THE   JAWS.  405 

fur  Klin.  Ghirunj.  (Band  xiii,  Heft  3)  the  case  of  a  man, 
a.gecl  twenty- seven,  who  was  admitted  into  hospital  with 
ankylosis  of  the  jaw  on  both  sides.  It  had  come  on  after 
an  attack  of  scarlet  fever  when  he  was  seven  years  old, 
being  preceded  by  severe  pain  in  the  part ;  and  since  the 
age  of  ten  he  had  not  been  able  to  move  the  jaw  at  all.  The 
secondary  dentition  was  attended  with  great  difficulty  in  the 
removal  of  the  milk  teeth  ;  and  the  new  teeth  were  irregu- 
larly developed,  and  for  the  most  part  were  displaced  late- 
rally. The  patient,  on  admission,  was  of  anaemic  appearance, 
though  in  moderately  good  condition ;  the  lower  jaw  was 
imperfectly  developed.  Speech  was  somewhat  muffled,  but 
was  quite  intelligible.  Not  the  least  movement  of  the  jaw 
could  be  produced  under  anaesthesia.  Herr  Middeldorpf 
operated  on  the  right  side,  removing  a  wedge-shaped  piece 
of  bone,  as  recommended  by  Esmarch,  near  the  angle.  The  ., 
result  of  this  was  the  formation  of  a  false  joint,  with  power  « 
of  opening  the  mouth  passively  to  the  extent  of  about  an 
inch.  Between  four  and  five  months  later,  Dr.  Fischer  per- 
formed a  similar  operation  on  the  left  side ;  four  months 
after  this  the  patient  could  voluntarily  open  his  mouth 
without  pain  to  the  extent  of  about  an  inch  and  a  quarter, 
and  his  general  condition  was  much  improved. 

The  treatment  of  cicatricial  contraction  within  the  mouth 
by  simple  division  has  been  proved  over  and  over  again  to  be 
perfectly  useless ;  but  when  suitable  apparatus  is  adapted 
to  the  jaws,  so  as  to  prevent  re-contraction,  a  very  good 
result  may,  with  patience,  be  produced  in  cases  uncomplicated 
by  destruction  of  the  cheek  itself. 

Fig.  186  shows  a  sketch  of  the  mouth  of  a  woman  who 
had  cicatricial  bands  on  each  side,  binding  the  cheeks  and 
gums  together  so  that  she  was  able  only  to  separate  the  lips, 
and  in  whom  division  of  the  cicatrices  had  been  practised  in 
childhood.  The  lower  jaw  was  edentulous,  but  the  upper 
front  teeth  remained,  and  Mr.  Felix  Weiss  succeeded  in 
adapting  a  small  lower  denture  so  as  to  antagonize  the 
upper  teeth  and  prevent  the  further  contraction  which  ap- 
peared imminent,  at  the  same  time  greatly  improving  the 


406 


CLOSURE   OF   THE   JAWS. 


patient's  power  of  articulation   {British  Journal  of  Dental 
Science,  May,  1880). 


Fig.  186. 


The  great  drawback  to  treatment  by  division  of  bands, 
and  one  witli  regard  to  whicli  it  contrasts  unfavourably  with 
Esmarch's  proceeding,  is  the  amount  of  pain  which  the  patient 
must,  of  necessity,  undergo  during  the  after-treatment.  It 
requires  no  small  amount  of  courage  on  the  part  of  the  jDatient, 
and  some  determination  on  the  part  of  the  attendant,  to  carry 
out  the  necessary  manipulations  within  the  mouth,  more  par- 
ticularly during  the  first  few  days  after  the  operation ;  and 
even  after  the  shields  are  fitted  to  the  mouth  they  cause 
some  pain  and  inconvenience,  which  only  those  who  have 
arrived  at  years  of  discretion  will  submit  to. 

Fig.  187  shows  the  form  of  the  silver  "  shields"  adapted 
to  the  upper  and  lower  jaws  by  the  late  Mr.  Clendon,  formerly 
dental  surgeon  to  the  "Westminster  Hospital,  in  a  case  of  Mr. 
Barnard  Holt's.  The  patient  was  a  girl  of  seventeen,  and 
was  under  Mr.  Holt's  care  in  1862,  having  five  years  before 
had  fever,  with  an  abscess  of  the  cheek  on  the  right  side, 
which  led  to  such  contraction  and  adhesion  of  the  mucous 
membrane  to  the  jaw  as  to  cause  great  difficulty  in  opening 


CLOSURE    OF   THE   JAWS. 


407 


the  mouth.  Some  attempts  had  heen  made  to  open  her 
mouth  by  the  screw,  &c.,  and  in  1860  Mr.  Holt  divided  some 
of  the  cicatrix  with  temporary  benefit,    Mr.  Holt  now  divided 


Fk;.  187. 


the  cicatrix  within  the  cheek  freely  under  chloroform,  and 
encountered  a  firm  plate  of  bone  extending  between  the 
alveoli  of  the  two  jaws,  which  necessitated  the  use  of  a  saw 
for  its  division.  Mr.  Clendon  subsequently  fitted  the  above- 
mentioned  shields  to  the  teeth,  and  wedges  were  gradually 

Fig.  188. 


introduced  between  them  to  separate  the  jaws.  This  treat- 
ment was  continued  for  three  months,  when  she  was  able  to 
open  the  mouth  to  the  full  extent,  as  seen  in  fig.  188. 


408  CLOSURE   OF   THE   JAWS. 

The  effect  of  tlie  use  of  the  shields  seems  to  have  been, 
not  merely  to  prevent  adhesions  between  the  inside  of  the 
cheek  and  the  alveolus,  but  to  re-establish,  to  a  great  extent, 
the  sulcus  of  mucous  membrane  at  the  base  of  the  alveolus, 
upon  which  so  much  stress  is  laid  by  Professor  Esmarch. 
Surgical  experience  in  cases  of  ruptured  perineum,  &c.,  sliows 
how  soon  mucous  membrane  is  reproduced  where  it  has  once 
existed,  or  even  appears  on  adjacent  parts  where  its  presence 
gives  rise  to  inconvenience  ;  and  there  can  be  no  question 
that  in  this  case  the  mucous  lining  of  the  cheek  has  been 
reproduced  to  a  great  extent,  and  particularly  near  the  lower 
alveolus.  Esmarch's  theory,  that  there  must  be  some  portion 
of  old  mucous  membrane  remaining  which  afterwards  be- 
comes stretched,  is  certainly  untenable  as  regards  this  case 
at  least,  for  without  doubt  the  whole  lining  of  the  cheek 
and  the  outside  of  the  alveoli  were  perfectly  raw,  owing  to 
the  division  of  the  firm  cicatrices. 

The  cause  of  non-success  in  former  attempts  at  mechanical 
appliances  is  to  be  found,  I  think,  in  the  fact  that  they  have 
all  been  directed  simply  to  keeping  the  jaws  apart,  without 
any  reference  to  the  re- establishment  of  the  mucous  lining 
of  the  cheek,  upon  which,  as  Professor  Esmarch  says,  the 
movements  of  the  jaw  so  much  depend.  That  the  success 
in  the  foregoing  case  depended  upon  this  is  proved,  I  think,  by 
the  existence  of  a  firm  band  in  the  cheek  which  would  effec- 
tually control  all  movement  were  its  extremities  attached  to 
the  two  alveoli ;  but  as  it  is,  it  gives  no  inconvenience,  and 
will,  in  all  probability,  atrophy  in  the  course  of  time. 

At  the  Odontological  Society,  in  June,  1864,  Mr.  Cart- 
wright  narrated  a  very  similar  case  of  contraction  (with  the 
exception  that  there  was  no  bony  bridge  between  the  alveoli), 
in  a  woman,  aged  thirty-eight,  which  he  successfully  treated 
by  similar  means,  using  w^edges  of  vulcanized  india-rubber 
affixed  to  the  shields  to  obtain  the  necessary  distension. 

The  occurrence  of  an  osseous  lamella  or  bridge  between 
the  two  jaws  is  a  rare  but  not  unique  occurrence.  In  the 
Medical  Gazette,  of  July  4,  1845,  Mr.  J.  G.  French  has 
reported  and  figured  an  excellent  example  of  ankylosis  pro- 


CLOSURE    OF   THE    JAWS.  409 

duced  by  a  bridge  of  bone,  which  occurred  under  his  care 
at  the  St.  James's  Infirmary. 

The  patient  was  twenty-two  at  the  time  of  his  death,  and 
the  closure  of  the  jaws  dated  from  infancy.  He  was  fed 
through  an  aperture  made  by  the  removal  of  the  incisors  on 
the  left  side.  At  the  age  of  fourteen  an  operation  for  his 
benefit  had  been  undertaken  by  an  eminent  surgeon,  and 
incisions  in  the  mouth  had  been  made  with  this  object,  but 
without  any  good  result.  On  post-mortem  examination  the 
jaws  were  perfectly  united  on  the  left  side,  and  only  the 
smallest  degree  of  motion  was  possible  on  the  right;  the 
soft  parts  were  removed  and  the  base  of  the  skull  was  mace- 
rated, when  ankylosis  was  discovered  to  exist  between  the 
upper  and  lower  jaws  on  the  left  side,  the  ramus  of  the  in- 
ferior maxilla,  immediately  internal  to  the  mental  foramen, 
extending  upwards  by  a  broad  thin  plate,  and  uniting  with 
a  correspondiug  plate  of  the  superior  maxilla,  a  cartilaginous 
material  forming  the  bond  of  union.  The  articulation  of 
the  jaw  was  normal. 

Mr.  Trueman  also  mentioned  in  the  discussion  whicli 
followed  the  narration  of  Mv.  Cartwright's  case  (British 
Journal  of  Dental  Science,  June,  1864)  that  he  remembered 
seeing  in  the  Museum  at  Berlin  a  very  curious  case  where 
cicatrices  existed  on  both  sides  of  the  mouth,  which  were 
completely  ossified,  so  that  the  preparation  showed  the  two 
jaws  united  by  filaments  of  bone,  on  either  side  of  the  jaw 
externally. 

Subsequently  to  Mr.  Holt's  case,  I  had  under  my  care  a 
patient  with  a  very  severe  form  of  contraction — viz.,  on  both 
sides  of  the  mouth.  The  patient  was  eighteen,  and  the 
contraction  dated  from  her  fifth  year,  when  she  had  fever. 
Various  attempts  had  been  made  to  give  her  relief  by 
dividing  the  cicatrices  and  using  wedges,  &c.,  without 
benefit ;  and  when  she  came  under  my  care  she  had  no 
power  of  separating  the  jaws  at  all,  and  the  cheeks  were 
firmly  attached  to  the  alveoli  from  the  angles  of  the  mouth. 
Having  secured  Mr.  Clendon's  co-operation,  I  freely  divided 
the  cicatrices^  and  after  repeated  trials  that  gentleman  sue- 


410  CLOSURE    OF   THE   JAWS. 

ceeded  in  fitting  in  shields  resembling  those  used  in  Mr. 
Holt's  case,  but  reaching  over  both  sides.  It  was  found 
necessary  to  extract  all  the  teeth,  and  after  more  than  three 
months'  assiduous  care  and  frequent  modification  of  the 
shields,  the  patient  being  constantly  placed  under  the  influ- 
ence of  chloroform  for  the  purpose,  a  very  satisfactory  result 
was  obtained,  there  being  exactly  one  inch  between  the 
metal  shields  in  tlie  incisive  region,  which  would  have  left 
about  half  an  inch  if  the  teeth  had  been  in  situ. 

In  order  to  contrast  the  permanent  results  of  this  method 
of  treatment  with  that  by  removal  of  a  portion  of  the 
jawj  I  may  mention  that  three  years  after  the  opera- 
tions, I  ascertained  the  following  facts  respecting  these 
patients : — 

Frances  H.,  the  girl  treated  by  Mr.  Holt  by  internal 
division  and  the  application  of  metal  shields,  wore  the  shields 
for  some  months  after  leaving  the  hospital,  but  discontinued 
them  after  some  eighteen  months.  The  contraction  had 
returned  to  some  extent,  the  band  which  existed  in  the 
cheek  having  shortened  so  as  to  diminish  the  extent  to 
which  she  could  separate  the  teeth  one-half — viz.,  from 
three- fourths  to  three-eighths  of  an  inch.  The  cheek  was 
slightly  tucked  in  owing  to  the  contraction ;  but  the  girl 
was  perfectly  well  and  comfortable,  and  would  not  allow 
any  interference  with  the  parts. 

Isabella  M'Nab  (my  patient  treated  by  metal  shields), 
whose  case  was  remarkable  owing  to  the  adhesions  being 
present  on  both  sides  of  the  mouth,  was  seen  by  Dr  Crockett, 
of  Dundee,  in  the  middle  of  1864,  and  that  gentleman  has 
kindly  sent  me  the  following  report  of  her  condition  : — 
"  The  jaws  can  be  oj)eBed  with  ease  to  the  extent  of  half  an 
inch  ;  she  has  begun  to  articulate  distinctly  within  the  last 
two  months,  and  within  the  last  fortnight  is  able  to  chew  a 
crust  of  bread,  having  some  lateral  motion  of  the  jaw.  A 
fetid  muco-purulent  discharge  continues  to  come  from  the 
mouth,  but  her  general  health  is  much  improved." 

Having  thus  shown  that  cases  of  closure  of  the  jaws  by 
cicatrices  are  amenable  to  two  modes  of  treatment  with  most 


CLOSURE   OF    THE   JAWS.  411 

satisfactory  results,  and  ha\dng  had  personal  experience  in 
carrying  out  both  methods,  I  shall  venture  to  draw  a  brief 
comparison  between  them. 

Esmarc]l^s  operation  is  a  comparatively  easy  proceeding ; 
and  in  cases  where  only  one  side  of  the  jaw  is  affected, 
restores  the  patient  a  very  useful,  though  one-sided,  amount 
of  masticatory  power  in  two  or  three  weeks,  and  with  very 
little  suffering  or  annoyance.  One  side  of  the  jaw  is,  how- 
ever, rendered  permanently  useless  (its  previous  condition), 
and  there  is  a  necessarily  resulting  deformity,  which  is  not 
however,  of  a  very  distressing  character.  The  paralysis,  from 
the  division  of  the  nerve,  is  so  slight  as  not  to  be  worthy 
of  mention. 

The  treatment  by  internal  division  and  the  use  of  metal 
shields,  is  applicable  to  all  cases  in  which  the  entire  thick- 
ness of  the  cheek  is  not  involved,  and  can,  with  due  care 
and  attention,  be  made  to  yield  most  satisfactory  results — 
the  patient  enjoying  the  full  use  of  both  sides  of  the  jaw, 
and  having  no  deformity  or  loss  of  sensation.  On  the  other 
hand,  the  operation  itself  is  difficult  and  bloody,  and  the 
after-treatment  is  tedious  and  troublesome  ;  and  it  is  essential 
for  success  to  have  the  co-operation  of  a  dental  practitioner 
fully  conversant  with  the  frequent  modifications  which  the 
metal  shields  must  necessarily  undergo.  The  age  of  the 
patient  is  an  important  element  also,  since  it  would  be  im- 
possible, I  imagine,  to  carry  out  the  treatment  with  any 
hope  of  success,  unless  the  patient  were  of  an  age  to  assist, 
or  at  least  not  to  resist,  the  surgeon.  In  my  own  case 
chloroform  was  resorted  to  on  every  occasion  of  real  opera- 
tive interference,  but  the  intermediate  treatment  was  much 
hindered  by  the  timid  character  of  the  patient. 


412 


CHAPTEE  XXVII. 

DISEASES   OF    THE    TEMPORO-MAXILLARY    AETICULATION. 

The  temporo -maxillary  articulation  is,  like  other  joints,  the 
subject  of  inflammation  due  to  constitutional  and  local 
causes,  to  which  latter  its  exposed  position  would  seem  to 
render  it  particularly  liable.  Yet  it  is  remarkable  that 
acute  disease  of  the  temporo -maxillary  joint  is  hardly  re- 
corded, and  I  think  the  explanation  is  to  be  found  in  the 
fact  that  it  is  often  confounded  with  acute  affections  of  the 
ear,  and  that  mischief  beginning  in  the  articulation  may 
induce  purulent  discharge  from  the  meatus  in  children. 

My  colleague,  Mr.  Arthur  Barker,  in  his  valuable  article 
on  Diseases  of  the  Joints  {System  of  Surgery,  vol.  ii.),  men- 
tions that  in  cases  of  suppuration  of  the  middle  ear,  the 
temporo-maxillary  articulation  may  become  involved  through 
the  floor  of  the  meatus,  in  which  a  hiatus  often  exists  in 
children.  He  quotes  in  proof  of  this  a  case  which  I  had 
long  under  my  care,  a  child,  from  whose  meatus  the  condyle 
of  the  jaw  was  extracted  ;  but  I  should  rather  regard  it  as  a 
case  in  which,  from  disease  of  the  temporo-maxillary  joint, 
perforation  had  ensued,  and  the  condyle  had  found  its  way 
into  the  meatus. 

That  destructive  disease  of  this  articulation  is  not  very 
infrequent,  is  evident  from  the  number  of  museum  speci- 
mens extant  of  complete  ankylosis,  and  of  the  numerous 
cases  of  flbrous  ankylosis  which  have  been  met  with  in 
practice. 

In  his  "Practical  Observations  in  Surgery"  (1816),  Mr. 
John  llowship  describes  a  case  of  "  scrofulous  inflammation 
of  the  face  followed  by  ankylosis  of  the  jaw"  in  a  man 
of  fifty-six  years  of  age,  wlio  dated  the  origin  of  the  disease 


TEMPORO-MAXILLARY   ARTICULATION. 


413 


from  a  cold  taken  at  the  age  of  four.  The  original  illus- 
tration shows  complete  bony  ankylosis  of  the  lower  jaw  to 
the  temporal  bone  on  the  left  side.  On  the  right  side  the 
shape  of  the  joint  is  considerably  modified,  as  may  be  seen 
in  the  specimen  in  the  College  of  Surgeons'  Museum  (19-19). 

In  Guy's  Hospital  Museum  is  the  skull  of  a  negro  who 
had  disease  of  the  cervical  vertebrtB,  and  complete  osseous 
ankylosis  of  the  temporo-maxillary  articulation,  coming 
on  after  a  wound  in  the  neck  from  a  fork.  The  history  of 
the  man,  with  a  drawing  of  the  skull,  will  be  found  in 
Mr.  Hilton's  "  Lectures  on  Eest  and  Pain." 

In  the  Museum  of  University  College  is  another  speci- 
men (849)  showing  an  earlier  stage  of  the  same  condition. 
The  condyle  is  immovably  united  to  the  corresponding  part 

Fig.  189. 


of  the  temporal  bone,  the  contiguous  surfaces  being  very 
irregular  but  mutually  adapted,  and  separated  in  part  by  a 
thin  line  of  shrunken  fibrous  tissue.  Considerable  portions 
of  each  of  the  surfaces  have  been  destroyed,  the  condyloid 
part  of  the  jaw  is  much  enlarged  in  the  antero -posterior 
direction,  so  as  to  lie  in  contact  both  with  the  glenoid  fossa 
and  the  articular  eminence  in  front  of  it.  Also,  in  St. 
Bartholomew's  Hospital  Museum  is  a  specimen  (I.  G64),  of 
which  I  have  been   allowed   to  take  a   drawing  (fig.  189), 


414  DISEASES    OF  THE 

showing  the  results  of  disease  of  the  right  articulation  for 
the  lower  jaw,  a  quantity  of  rough  new  bone  having  been 
formed,  from  which  the  condyle  appears  to  have  forcibly 
broken  away. 

Cases  of  fibrous  ankylosis  of  the  temporo-maxillary  articu- 
lation, recognized  and  treated  as  such  during  life,  have  been 
recorded  by  several  surgeons,  but  I  would  especially  refer 
to  two  published  by  Mr.  Spantou,  of  Hanley  {Lcmcd,  April 
16,  1881),  because  that  gentleman  proved  the  correctness  of 
his  diagnosis  by  dividing  the  fibrous  bands  with  a  tenotome 
passed  into  the  articulation^  and  then  succeeded  in  screwing 
open  the  mouth.  The  patients  were  girls,  aged  ten  and 
nine  respectively,  and  in  both  cases  the  disease  of  the  tem- 
poro-maxillary joint  had  followed  scarlet  fever. 

I  have  had  the  opportunity  of  watching  a  case  which  I 
fear  will  terminate  in  ankylosis  of  the  jaw,  in  a  gentleman 
aged  twenty-five,  who  was  sent  to  me  by  my  friend,  Mr. 
Bate,  I  saw  him  first  in  February,  1866,  when  he  told  me 
that  he  had  the  measles  badly  when  nine  years  old,  and 
this  was  followed  by  discharge  from  the  left  ear^  which 
became  deaf.  The  discharge  had  ceased  for  two  years,  when 
in  September,  1864^  he  caught  a  severe  cold,  and  it  recom- 
menced, and  at  the  same  time  the  left  temporo-maxillary 
articulation  became  swollen  and  stiff,  so  that  he  was  obliged 
to  live  by  suction  for  some  time.  The  discharge  from  the 
ear  was  very  profuse,  as  much  as  half  a  pint  at  a  time,  and 
matter  burrowed  under  the  tissues  of  the  face  as  higli  as  the 
orbit,  where  a  small  opening  formed,  and  down  the  neck, 
discharging  into  the  throat  for  three  days.  Finding  the 
left  lower  wisdom  tooth  cut  awry  and  very  far  back,  I 
thought  that  this  might  possibly  1)0  connected  with  the 
disease,  and  therefore  had  it  extracted,  with  some  difficulty, 
by  Mr.  Mummery.  In  the  following  July  I  found  that  he 
had  derived  no  benefit  from  the  extraction,  and  the  jaws 
were  as  firmly  closed  as  before.  The  space  between  the 
incisors  was  \  inch,  and  rather  more  between  the  bicuspids 
on  the  left  side.  The  mouth  did  not  open  so  widely  as  it 
had  done  eighteen  months  before,  but  he   had  perceived  no 


TEMPORO-MAXILLARY   ARTICULATION.  415 

difference  during  tlie  preceding  six  months.  There  was  no 
external  deformity,  but  he  said  he  heard  a  grating  sound  on 
moving  the  jaw,  which  was  not  audible  externally. 

Tliis  would  appear  to  have  been  a  case  of  inflammation  and 
destruction  of  the  temporo-maxillary  articulation,  whicli  was 
undergoing  cure  by  ankylosis,  as  would  happen  with  other 
joints  under  similar  circumstances.  It  cannot  be  classed 
with  the  cases  of  chronic  rheumatic  arthritis  of  the  joint, 
since  the  patient  had  none  of  the  symptoms  of  that  disorder. 

The  only  disease  of  the  temporo-maxillary  joint  hitherto 
generally  recognized  by  surgical  authors,  has  been  the  so- 
called  "  sub-luxation"  of  Sir  Astley  Cooper.  It  is  an  affec- 
tion occurring  principally  in  delicate  women,  and  has  been 
thought  to  depend  upon  relaxation  of  the  ligaments  of  the 
joint  permitting  a  too  free  movement  of  the  bone,  and  pos- 
sibly (though  this  is  conjecture)  a  slipping  of  the  inter- 
articular  cartilage.  From  a  considerable  acq\iaintance  with 
this  affection,  I  believe  that  it  is  in  many  cases,  at  least, 
unconnected  with  any  slipping  of  the  cartilage,  but  is  due 
to  rheumatic  or  gouty  changes  in  the  articulation.  The  fact 
that  these  patients  suffer  most  in  damp  weather  and  when 
the  general  health  is  feeble,  shows  that  it  depends  upon  an 
arthritic  diathesis,  and  the  relief  that  is  obtained  from 
counter- irritation  and  the  exhibition  of  anti-rheumatic  or 
anti-gouty  remedies,  proves  that  the  complaint  cannot  be  due 
to  purely  mechanical  causes. 

The  researches  of  the  late  Dr.  Kobert  Adams  and  Dr. 
E.  W.  Smith,  of  Dublin,  have  shown  that  rheumatoid  arthritis 
occasionally  affects  the  temporo-maxillary  articulation,  and 
the  former  author  has,  in  his  "  Atlas,"  figured  the  remark- 
able hypertrophy  of  the  neck  of  the  condyle  of  the  jaw, 
occurring  in  the  case  of  a  woman,  aged  thirty,  to  which  I 
shall  have  occasion  to  refer  more  particularly  later  on. 

Cruveilhier,  who  first  described  an  example  of  rheumatoid 
arthritis  of  the  temporo-maxillary  articulation  ("Anatomic 
Pathologique,"  liv.  ix.),  says  : — "I  have  never  seen  the  disease 
I  call  wearing  away  of  the  articular  cartilages  better  marked 
than  it  was  in  this  case.     The  condyle  of  the  lower  jaw  did 


416 


DISEASES   OF   THE 


not  exist ;  it  might  be  supposed  to  liave  been  sawn  off 
horizontally  at  the  line  of  junction  of  the  head  with  the 
neck,  and  that  which  remained  of  the  neck  had  been  flat- 
tened.    The  articular  part  of   the  glenoid  cavity  was  repre- 


FiG.  190. 


Fig.  191. 


sented  merely  by  a  plane  surface  ;  no  trace  of  inter-articular 
cartilage  or  cartilage  of  incrustation  existed.  Both  surfaces 
of  the  altered  articulation  were  remarkably  red." 

I  have  never  had  the  opportunity  of  examining  a  recent 
example  of  this  disease,  but  as  far  as  can  be  judged  from 
museum  specimens,  the  articular  surface  of  the  condyles  is 
flattened  and  somewhat  altered  in  direction  in  the  less 
marked  instances    (fig.    190),    and  absorption  of   the  neck, 

Fig.  192. 


•>    ■'\'  '    ^\i!>\^^'  \^  \-  X^^JifS 


with  complete  wearing  away  of  the  articular  surfaces  (fig. 
191),  occurs  in  the  older  and  more  advanced  cases.  I  agree 
with  Dr.  Adams,  that  eburnation  of  the  articular  surfaces, 
or  the  occurrence  of   porcellanous  deposit  in  the  temporo- 


TEMPORO-MAXILLARY    ARTICULATION. 


417 


maxillary  articulation,  is  very  rare.  The  description  quoted 
from  the  St.  Bartholomew's  Catalogue  by  Dr.  Adams  refers 
to  preparation  No.  551  in  that  museum  (fig.  192),  and  is  as 
follows  : — 

"  There  has  been  disease  in  one  of  the  articulations  of  the 
jaw,  producing  absorption  of  the  articular  cartilage,  with  a 
deposit  of  bone  around  the  circumference  of  the  glenoid 
cavity.  The  corresponding  condyle  is  in  part  removed  by 
absorption ;  its  surface  is  rough,  except  at  one  point,  where 
it  is  highly  polished  and  has  an  ivory-like  texture." 

Enlargement  of  the  glenoid  cavity  is  common  in  these 
cases,  and  is  well  seen  in  fig.  193,  taken  from  the  same  speci- 
men in   St.    Bartholomew's  Hospital.     Absorption  of  bone 

Fig.  19;1. 


must  of  course  occur  in  these  cases,  but  it  is  worthy  of 
remark  that,  as  pointed  out  by  Dr.  Adams,  the  bone  forming 
the  fundus  of  the  cavity  is  not  thinned,  but^  if  anything, 
is  thicker  than  in  the  normal  state.  The  entire  disappear- 
ance of  the  inter-articular  fibro-cartilage  is,  apparently,  an 
early  event  in  chronic  disease  of  the  temporo-maxillary 
articulation.  It  had  entirely  disappeared  in  all  the  few 
recorded  post-mortem  examinations,  and  was  absent  in  a 
case  of  hypertrophy  of  the  condyle  in  the  living  subject 
which  I  successfully  operated  upon. 

E  E 


418 


DISEASES    OF   THE 


Kyijertropliy  of  the  Neck  and  Condyle  was  observed  by  Dr. 
Adams  in  the  case  of  rheumatoid  arthritis  of  the  temporo- 
maxillary  joint  already  referred  to^  and  is  beautifully  shown 
in  Plate  1  of  his  admirable  "  Atlas."  Though  occurring  in  a 
woman  of  only  thirty,  there  can,  I  think,  be  no  doubt,  from 
the  description  and  drawings  of  her  hand  and  feet,  that  the 
patient  was  the  subject  of  rheumatoid  arthritis.  It  is  by  no 
means  certain,  however,  that  the  hypertrophy  of  the  neck 
and  condyle  must  be  considered  to  be  the  results  of  that 
disease,  for,  as  I  shall  show,  this  same  rare  deformity  has 
been  found  in  patients  otherwise  healthy. 

Fig.  19Jr  shows  a  lower  jaw  so  like  that  figured  in  Adams' 
"  Atlas"  in  every  respect,  that  the  preparations  are  evidently 

Fig.  194. 


identical  in  their  nature.  It  was  presented  to  the  College 
of  Surgeons'  Museum  (2205)  by  Mr.  Jeremiah  McCarthy, 
and  is  thus  described  by  Mr.  Eve  : — 

"  A  lower  jaw  with  a  mass  of  bone,  having  somewhat  the 
form  of  an  inverted  pyramid,  attaclied  to  the  thickened  neck 


TEMPORO-MAXILLAKY   ARTICULATrON. 


419 


of  the  right  condyloid  process.  The  upper  surface  of  the 
mass,  corresponding  to  the  base  of  the  pyramid,  is  flat  and 
smooth  as  if  it  had  been  covered  with  fibro-cartilage  (fig. 
195).  Upon  its  inner  side  is  a  deejD  indentation^  from  which 
a  fissure  extends  outwards  and  downwards  nearly  to  the 
external  surface  of  the  bone.  The  indentation  and  the  fissure 
constitute  the  upper  boundary  of   a  portion  of  bone  which, 

Fig.  195. 


from  its  form  and  position,  might  be  taken  for  an  enlarged 
condyle.  The  right  half  of  the  jaw  is  larger  in  all  its  dimen- 
sions than  the  left  half,  the  breadth  of  the  horizontal  ramus 
in  front  of  the  angle  being  double  that  on  the  left  side, 
which,  from  the  slenderness  of  the  coronoid  and  condyloid 
processes,  appears  atrophied.  From  a  middle-aged  man,  who 
died  with  apoplexy.  There  was  a  remarkable  deformity  of 
the  face  from  the  deviation  of  the  symphysis  from  the  middle 
line ;  and  the  projection  of  the  enlarged  condyle  was  con- 
siderable. The  base  of  the  skull  was  not  examined,  and 
nothing  was  found  in  the  post-mortem  examination  except 
atheroma  of  the  vessels.  Nothing  unusual  had  been  noticed 
about  his  mouth  in  childhood,  nor  could  any  account  of  an 

E  E  2 


420  DISEASES    OF    THE 

injury  be  obtained."      (See  Pathological  Society's  Transactions, 
vol.  xxxiv.,  1883.) 

In  the  same  volume  of  the  Pathological  Society's  Transac- 
tions Avill  be  found  the  record  of  a  remarkable  specimen  of 
hypertrophy  of  the  neck  and  condyle  of  the  jaw,  removed 
by  myself  from  a  woman,  aged  thirty-six,  whose  face  had 
for  ten  years  become  gradually  more  deformed,  by  the  in- 
creasing displacement  of  the  chin  to  the  right  side  and  the 
projection  outwards  of  the  left  condyloid  process.  The 
movements  of  tlie  jaw  were  restricted,  and  the  length  of  the 
left  ascending  ramus  was  three  inches,  of  the  right  one  inch 
and  a  half.  She  liad  an  attack  of  hemiplegia,  implicating 
the  left  side  of  the  face,  when  she  was  twenty-five  years 
of  age,  and  from  this  affection  her  limbs  had  recovered 
perfectly  and  her  face  partially. 

Fig.  196. 


The  appearance  of  the  patient  (who  was  sent  to  me  by  Dr. 
Williams,  of  Sherborne)  is  seen  in  fig.  196,  and  the  piece  of 
bone  removed  is  accurately  drawn  in  the  lithographic  plate 
(v.  frontispiece),  the  hypertrophied   condyle  measuring  one 


TEMPORO -MAXILLARY   ARTICULATION.  421 

inch  and  three-quarters  from  before  iDackwards,  and  one  inch 
across,  and  being  covered  with  fibro-cartilage.  A  section  of 
the  preparation  sliows  it  to  be  composed  of  cancellous  bone 
with  large  rounded  sj)aces,  and  its  walls  are  formed  of  a  thin 
layer  of  compact  bone.  The  fissure  observed  in  Mr.  ]\IcCarthy's 
does  not  exist  in  this  specimen,  If  the  condyle  thus  shown  is 
compared  with  fig.  195,  which  represents  the  condyle  of  Mr. 
McCarthy's  case,  of  the  natural  size,  there  can  be  little  doubt 
that  my  preparation,  Mr.  McCarthy's,  and  Dr.  Adams's  all 
belong  to  the  same  category ;  and  yet  in  Mr.  McCarthy^s 
probably,  and  certainly  in  my  own  case,  this  was  the  only  joint 
affected.  It  must  be  concluded  then,  I  think,  that  hypertrophy 
of  the  neck  and  condyle  may  occur  in  otlierwise  healthy 
patients,  and  I  believe  that  I  saw,  in  consultation  with  Mr. 
Nathaniel  Stevenson,  the  early  stage  of  this  curious  con- 
dition in  a  young  healthy  lady  of  about  twenty,  in  whom 
the  lower  teeth  had  gradually  become  displaced  from  no 
known  cause,  so  as  to  disarrange  the  normal  bite.  I  here 
detected,  what  was  then  new  to  me,  some  hypertrophy  of  the 
neck  of  the  jaw  on  one  side,  and  recommended  blistering  and 
a  course  of  iodide  of  potassium  without  any  marked  benefit, 
except  that  the  deformity  has  not  increased.  In  the  patient, 
whose  portrait  is  given  in  fig.  196,  the  deformity  was  so  great 
as  to  warrant  surgical  interference,  and  the  result  has  been 
very  satisfactory,  the  face  being  brought  straight  and  the 
patient  having  free  movement  of  the  jaw. 

The  Treatment  of  inflammation  of  the  tempore -maxillary 
joint  has  hitherto  been,  in  chronic  cases,  the  application  of 
blisters  and  the  use  of  a  bandage — particularly  an  elastic 
bandage  at  night.  Dr.  Goodwillie,  of  ISTew  York,  has,  how- 
ever, contrived  an  ingenious  method  of  fixing  the  lower  jaw 
effectually  in  cases  of  arthritis,  which  will  be  best  described  in 
his  own  words  (Archives  of  Medicine,  New  York,  June,  1881) : — 

"  The  method  that  I  employ  is  as  follows :  In  this  case 
the  patient  is  under  the  anesthetic  effect  of  morphine  and 
nitrous  oxide.  If  there  is  any  rigidity  of  the  muscles,  cau- 
tiously force  open  the  mouth  and  take  an  impression  of 
either  the  upper  or  lower  teeth,  and  a  rubber  splint  is  made 


422 


DISEASES   OF    THE 


from  the  cast  to  cover  over  all  the  teeth  in  one  jaw.  Upon 
the  posterior  part  of  this  splint  is  made  a  prominence  or 
fulcrum  {D),  so  that  when  the  mouth  is  closed  the  most 
posterior  teeth  close  upon  it,  while  all  the  anterior  teeth  are 
left  free.  The  next  step  is  to  take  a  plaster  of  Paris  im- 
pression of  the  chin,  and  from  this  make  a  splint  {A).  On 
each  end  of  the  splint  is  made  a  place  for  fastening  elastic 
straps  [B)  that  pass  up  on  each  side  of  the  head  to  a  close- 
fitting  skull-cap  (C).     See  fig.  197. 

"  When  the  apparatus  is  in  place  and  the  elastic  straps 
tightened  so  as  to  lift  the  chin,  then  pressure  is  brought  to 
bear  on  the  fulcrum  at  the  posterior  molar  tooth,  and  so  by 
this  means  extension  is  made  at  the  joints,  and  the  inflamed 
surfaces  within  the  joints  are  relieved  from  pressure  ;  then 
immediate  relief  is  experienced." 

Fig.  197. 


I  have  no  experience  of  this  method,  but  it  appears  to  be 
based  upon  sound  surgical  principles,  and  the  cases  illustra- 
tive of  its  use  given  by  Dr.  Goodwillie  attest  its  usefulness. 

In  the  cases  of  fibrous  ankylosis  resulting  from  the  cure  of 
arthritis,  it  is  open  to  the  surgeon  to  have  recourse  to  me- 
chanical means  to  break  down  the  adhesions,  and  to  illus- 


TEMPORO- MAXILLARY   ARTICULATION.  423 

trate  the  difficulties  to  be  overcome,  I  may  refer  to  another 
case  of  Dr.  Gooclwillie's  {Ncio  York  Medical  Journal,  July, 
1875)  : — The  patient  was  a  girl  of  ten,  who,  five  years  be- 
fore, had  fallen  over  the  bannisters,  breaking  and  dislocating 
the  jaw,  M'ith  the  result  of  the  jaws  being  firmly  closed. 
The  apparatus  employed  is  seen  in  fig.  198. 

Fig.  198. 


One  of  the  chief  sources  of  interruption  in  treatment  is 
periodontitis  from  the  great  amount  of  force  used  on  the 
teeth.  To  prevent  this,  Dr.  Goodwill ie  protects  them  with 
an  interdental  splint  of  hard  rubber.  These  splints  at  first 
are  necessarily  very  small,  and  confined  to  the  front  teeth ; 
but,  as  the  case  progresses,  longer  and  more  perfect  ones  are 
made.  In  this  case  the  rubber  splints  were  enclosed  in 
metal  splints  made  of  German  silver,  as  this  metal  is  tough 
and  unyielding.  These  splints  were  made  fast  to  the  teeth 
by  straps  that  passed  from  strong  wire  arms  at  the  sides  to  a 
skull-cap,  and  the  lower  one  was  strapped  to  a  pad  on  the 
chin.  This  pad  was  also  attached  to  the  lower  s^^lint  by 
means  of  a  ratchet  and  spring. 

From  the  point  of  each  splint  an  arm,  three- fourths  of 
an  inch  broad,  extends  out  one  and  a  quarter  inch,  and  to 
these  is  clasped  the  oral  speculum  when  in  use  (tig.  198). 
The  inclined  planes  of  the  speculum  pass  in  between  these 
arms,  and  they  are  held  by  clasps.  The  inclined  planes 
are  attached  by  movable  joints  to  a  distending  forceps,  so 
that  when  the  handles  are  approximated,  the  inclined  planes 
are  separated  at  their  attached  ends.     Each  handle  is  made 


424 


DISEASES    OF   THE 


in  two  sections,  and  tlie  spring  that  separates  the  handle  is 
enclosed  between  them  to  protect  them  from  injury. 

In  forcing  the  speculum  between  the  splints,  the  instru- 
ment is  grasped  by  one  of  the  handles,  and  when  in  place 
both  handles  are  approximated.  If  more  force  is  desired, 
or  the  mouth  is  to  be  held  open  at  any  point,  the  screw  at 
the  handle  may  be  used. 

In   stretching  the   masseter   and   temporal  muscles,   Dr. 


Fig.  199. 


Fig.  200. 


Goodwillie  uses  au  oral  speculum,  devised  by  him  some 
years  ago  (fig.  199).  It  consists  of  a  .shaft,  to  the  flat  end 
of  which  are  attached  two  wings  or  inclined  pilanes,  upon 
which  the  teeth  rest.  The  other  end  of  the  shaft  has  a 
thread  cut  on  it,  and  a  screw  ;  this  passes  through  a  handle, 
one  end  of  which  is  wedge-shaped.  By  turning  the  screw 
on  the  other  end  of  the  handle,  the  inclined  planes  diverge 
or  converge.  Fig.  200  represents  a  spiral-spring  speculum 
for  the  patients  to  employ  by  placing  it  between  the  teeth 
and  biting  upon  it.  Longer  springs  are  used  as  the  mouth 
gradually  opens. 

It  need  hardly  be  said  that  treatment  by  this  method 
would  extend  over  many  months,  and  would  severely  try  the 
endurance  of  both  patient  and  surgeon. 

A  simpler  method  is  the  division  of  adhesions  formed 
between  the  condyle  and  glenoid  cavity,  as  practised  by  Mr. 
Spanton  in  the  cases  already  referred  to,  in  both  of  which, 
as  I  learn  from  that  gentleman,  a  good  result  ensued.  I 
have  no  experience  of  the  proceeding,  and  it  has  its  diffi- 
culties, but  these  may  doubtless  be  overcome. 

Lastly,  there  is  in  cases  of  fibrous  ankylosis  the  possibility 


TEMPORO-MAXILLARY   ARTICULATION.  425 

of  removing  the  condyle,  as  has  been  done  by  Mr.  Davies- 
Colley,  and  probably  by  others  ;  or,  as  proposed  by  Dr. 
Ewing  Mears  {American  Journal  of  Medical  Science,  Oct. 
1883)j  to  divide  the  ramus  of  the  jaw  and  excise  the  condyle 
with  the  coronoid  process  and  sigmoid  notch. 

A  case  of  removal  of  both  condyles  for  fibrous  ankylosis  is 
quoted  by  the  Wiener  Med.  Wochensehrift,  of  July  6,  1872, 
from  the  proceedings  of  the  Eoyal  Academy  of  Medicine  in 
Bologna.  It  occurred  in  the  practice  of  Dr.  Bottini.  The 
patient  was  a  lad,  aged  seventeen,  who,  at  the  age  of  seven, 
had  fallen  on  the  jaw,  and  had  gradually  lost  the  power  of 
opening  his  mouth,  so  that  at  last  for  some  months  he  was 
unable  to  separate  the  jaws  to  any  extent.  Dr.  Bottini 
introduced  wedges,  but  these  were  vaiy  irksome  to  the 
patient,  and  were  removed.  Eesection  of  the  articular  head 
of  the  bone  was  then  performed  on  one  side ;  this  had  no 
noticeable  result,  but  on  the  operation  being  repeated  on  the 
other  side,  the  jaw  could  be  moved  freely.  At  the  end  of 
six  weeks  the  wound  had  healed,  and  the  motion  of  the  jaw 
was  normal.  The  only  morbid  change  that  could  be  dis- 
covered was  absence  of  the  inter-articular  fibro-cartilage. 

In  cases  of  rheumatoid  arthritis  in  which  the  suffering  is 
great,  and  in  cases  of  osseous  ankylosis  of  the  temporo- 
maxillary  articulation^  excision  of  the  condyle  seems  to  offer 
the  best  means  of  giving  relief.  The  first  removal  of  the 
condyle  was  by  Professor  Humphry,  of  Cambridge  {Associa- 
tion Med.  Journal,  1856),  and  was  undertaken  for  chronic 
rheumatic  arthritis.  He  exposed  the  condyle  by  a  curved 
incision  from  the  side  of  the  orbit  across  the  zygoma  to  the 
ear,  passing  a  little  above  the  temporo-maxillary  articula- 
tion, and  a  second  incision  from  the  termination  of  the  first 
directly  upwards  in  front  of  the  ear  across  the  zygoma  again, 
avoiding  the  temporal  artery.  The  flap  thus  made  was 
reflected,  and  the  neck  of  the  condyle  cut  through  with  a 
narrow  saw. 

In  cases  of  complete  synostosis,  resection  of  tlie  condyle 
appears  to  offer  the  best  and  safest  method  of  treatment.  In 
1874  Dr.  Gross,  of  Philadelphia,  resected  the  condyle  with  a 


426  DISEASES   OF   THE 

portion  of  the  neck  of  the  jaw  in  a  girl  of  seven,  but  does 
not  mention  the  method  he  pursued.  Mr,  Croft  has  shown 
me  the  photographs  of  a  child  in  whom  he  resected  the 
condyle  on  both  sides  consecutively,  with  very  good  results, 
and  no  doubt  the  oj)eration  has  been  performed  by  other 
surgeons.  In  1883  I  exposed  the  ankylosed  joint  in  a  boy  of 
seven  by  an  incision  in  front  of  the  ear,  and  with  a  cliisel 
divided  the  neck  of  the  bone,  and  removed  half  an  inch  of 
bone  in  the  situation  of  the  condyle,  with  very  good  results 
as  regards  movement,  and  with  no  obvious  damage  to  the 
facial  nerve. 

A  case  of  complete  synostosis  of  the  jaw  was  successfully 
treated  by  a  different  method  by  Dr.  James  Little,  of  New 
York,  in  1873  {Trans.  Ne-io  York  State  Med.  Soc,  1874). 
The  patient  was  nineteen  years  of  age,  and  had  some  years 
before  suffered  from  suppuration  of  the  temporo-maxillary 
articulation,  leading  to  ankylosis.  Dr."  Little  made  an  in- 
cision along  tlie  lower  border  of  the  jaw,  and  turned  up  the 
masseter,  when  the  neck  of  the  condyle  was  seen  to  be  very 
much  enlarged,  and  continuous  with  the  temporal  bone. 

A  trephine  half  an  inch  in  diameter  was  then  applied, 
and  a  button  of  bone  §  of  an  inch  in  thickness  was  removed. 
The  portion  of  bone  on  each  side  of  the  opening  was  then 
cut  through  with  a  chisel,  and  the  neck  of  the  condyle  cut 
away  piece  by  piece,  so  as  to  leave  no  portion  projecting 
from  the  temporal  bone.     The  result  was  quite  satisfactory. 

A  similar  operation,  but  performed  by  a  different  method, 
was  successfully  undertaken  by  Dr.  Robert  Abbe,  of  New 
York  (Hew  York  Medical  Journal,  April,  1880),  in  a  boy  of 
ten,  who  had  suffered  from  otitis  media  and  suppuration  of 
tlie  joint  some  years  before.  A  vertical  incision  was  made 
in  front  of  the  ear,  and  a  horizontal  one  meeting  its  upper 
end  was  carried  along  the  lower  border  of  the  zygoma.  The 
parotid  witli  tlie  facial  nerve  was  drawn  down,  and  with  a 
periosteal  elevator  the  posterior  fibres  of  the  masseter  were 
cleared  away,  and  the  articulation  exposed.  A  narrow 
osteotomy  chisel  was  now  applied  to  the  neck  of  the  condyle, 
and  carefully  driven  half  through  the  bone,  and  by  forcibly 


TEMPORO-M AXILLARY   ARTICULATION.  427 

opening  the  mouth  the  bone  was  broken  tlirough.  The  neck 
of  the  condyle  was  then  carefully  removed  piecemeal,  but  the 
condyle  was  left  in  situ.      The  result  was  satisfactory. 

Sedillot  mentions  ('^  Medecine  Operat.,"  ii.  p.  30)  that  in 
a  case  of  true  ankylosis  of  the  temporo-maxillary  articula- 
tion, M.  Grube,  in  1863,  carried  a  straight  chisel  through 
the  mouth  to  the  neck  of  the  jaw,  which  broke  by  hammer- 
ing. Some  months  later  he  divided  the  masseter  subcuta- 
neously,  and  the  cure,  by  the  formation  of  a  false  joints  was 
permanent.  In  1879,  I  performed  the  same  operation  in  a 
child  of  six,  but  the  results  were  unsatisfactory.  Suppura- 
tion was  set  up,  and  required  an  external  opening,  and  the 
movement,  which  was  free  at  firsts  became  as  limited  as 
before  the  operation.  It  would  appear,  therefore,  that  mere 
division  of  the  neck  of  the  bone  does  not  offer  such  good 
prospect  of  a  permanent  false  joint  as  removal  of  the  neck 
or  the  condyle,  though  these  operations  are  necessarily  more 
severe. 

Esmarch's  operation  performed  in  front  of  the  masseter  is 
of  course  as  applicable  to  cases  of  ankylosis  from  disease  of 
the  joint  as  to  cases  of  cicatrix,  and  Fischer  (British  Med. 
Journ.,  June  1,  1872)  appears  to  have  performed  the  opera- 
tion on  both  sides  of  the  jaw  in  a  case  of  bilateral  ankylosis 
of  the  temporo-maxillary  articulation  with  very  good  result, 
the  patient  obtaining  complete  and  useful  control  over  the 
central  movable  portion  of  the  jaw. 


428 


CHAPTEE  XXYIII. 

DEFORMITIES    OF    THE    JAWS. 

The  scope  of  this  work  does  not  embrace  those  congenital 
deformities  of  the  gum  and  palate  which  are  familiar  to  the 
surgeon  in  combination  with  hare-lip,  but  there  are  certain 
examples  of  deformity,  the  result  of  disease,  which  may  be 
conveniently  grouped  together  liere. 

In  describing  the  tumours  of  the  jaw,  mention  has  been 
made  and  drawings  given  of  cases  of  deformity  the  result  of 
pressure  upon  the  opposite  jaw  of  some  growth  of  large  size  ; 
thus,  at  page  332  will  be  found  an  instance  of  deformity  of 
the  upper  jaw,  due  to  the  pressure  of  a  large  fibrous  tumour 
of  the  lower  jaw ;  and  at  page  278  an  example  of  deformity 
of  the  lower  jaw,  due  to  the  pressure  of  a  large  osseous 
tumour  of  the  superior  maxilla.  Tumours  within  the  mouth, 
unconnected  with  the  jaws,  may,  however,  induce  deformity 
mechanically,  hypertrophy  of  the  tongue  being  the  disease 
most  frequently  met  witli,  of  whicli  several  instances  will  be 
found  in  vol.  xxxvi.  of  the  Medico- Chirurgical  Transactions, 
in  papers  upon  that  disease,  by  Dr.  Humphry,  of  Cambridge, 
and  Mr.  Josepli  Hodgson.  Dr.  Humphry's  patient  was  a 
girl  of  eleven  years,  who  liad  had  a  mucli  hypertrophied  and 
prolapsed  tongue  for  eight  years.  "  Owing  to  the  constant 
pressure  of  tlie  tongue  on  the  mental  portion  of  the  lower 
jaw  a  curvature  had  taken  place  in  that  bone,  just  in  front 
of  the  masseter  muscles,  in  such  a  manner  that  a  wide 
interval  always  existed  between  the  incisors  and  bicuspids  of 
the  two  jaws.  Even  wlien  the  mouth  was  closed — that  is  to 
say,  when  the  corresponding  molar  teeth  were  in  contact — 


DEFORMITIES    OF    THE   JAWS.  429 

this  interval  between  the  incisors  measured  nearly  two 
inches,  being  increased  by  the  horizontal  direction  which 
the  inferior  incisors  and  the  alveolar  process  of  the  lower 
jaw  had  assumed.  These  were  so  placed  as  to  form  a  wide 
channel  in  which  the  tongue  rested.  Moreover,  the  teeth, 
especially  the  two  central  incisors,  were  further  apart  than 
natural,  and  encrusted  with  tartar,  which  in  some  measure 
filled  up  the  spaces  between  them,  and  prevented  their 
sharp  edges  from  injuriously  pressing  upon  the  tongue." 
The  deformity,  therefore,  closely  resembled  that  seen  in 
fig.  201,  which  was  due,  however,  to  external  causes.  Dr. 
Humphry  removed  the  anterior  part  of  the  tongue  success- 
fully, and  then  endeavoured  to  remedy  the  deformity  of  the 
jaw  by  fitting  a  cap  of  calico  and  metal  to  the  head,  with 
a  hooked  bar  of  iron  projecting  from  it  like  a  horn  over  the 
forehead.  The  bar  was  attached  to  the  hinder  part  of  the 
framework  of  the  cap  by  a  hinge  and  to  the  forepart  by  a 
screw,  which  enabled  the  surgeon  to  alter  its  elevation 
according  to  circumstances.  A  thick  belt  of  india-rubber 
passed  from  the  hook  beneath  the  chin,  and  exerted  con- 
siderable pressure  upon  it.  The  apparatus  was  worn  for 
several  hours  at  a  time.  Wlien  its  use  was  commenced,  on 
January  18,  four  months  after  the  operation  on  the  tongue, 
the  interval  between  the  maxillary  alveoli  was  1§  inch, 
having  decreased  about  a  quarter  of  an  inch.  On  February 
22  it  was  IJ  inch,  and  in  August  f  of  an  inch.  After  this 
the  change  took  place  very  slowly,  though  the  deformity 
was  at  length  almost  removed. 

A  very  similar  condition  of  the  lower  jaw,  but  in  an 
earlier  stage,  existed  in  a  child  aged  three,  from  whom  Sir 
J.  Paget  successfully  removed  the  hypertrophied  portion  of 
the  tongue,  in  February,  1864.      {Lancet,  April  16,  1864.) 

Mr.  Oliver  Chalk  has  also  narrated,  in  the  Pathological 
Transactions,  vol.  viii.,  a  case  of  deformity  of  the  jaw  de- 
pendent upon  enlargement  of  the  tongue  in  which  he  con- 
sidered that  a  partial  dislocation  of  the  jaw  was  produced, 
and  where  benefit  was  derived  from  the  use  of  an  elastic 
support. 


430  DEFORMITIES    OF   THE    JAWS. 

The  influence  of  the  habit  of  sucking  the  thumb  upon 
the  position  of  the  front  teeth  is  generally  acknowledged, 
and  the  practice  if  persisted  in,  may  produce  very  con- 
siderable deformity  of  the  jaws.  Some  drawings  illustrating 
a  paper  on  this  subject,  by  Mr.  A^'asey,  in  the  Pathological 
Transactions,  vol.  vi.,  show  the  resulting  deformity  ex- 
tremely well.  Dr.  Thomas  Ballard  has  also  called  attention 
to  the  deformity  resulting  from  the  habit  of  "  tongue- 
sucking,"  to  which  he  attributes  many  of  the  ailments 
of  cliildren. 

The  influence  of  cicatrices  outside  the  mouth  in  pro- 
ducing deformity  of  the  jaw  by  their  contraction  in  early 
life  is  well  ascertained,  and  every  surgeon  must  have  met 
with  painful  examples  of  the   kind.      Fig.   201,   from  Mr. 

Fig.  201. 


Tomes'  work,  shows  the  condition  of  the  lower  jaw  in  a 
young  woman  twenty-two  years  of  age,  her  chin  having 
been  drawn  down  towards  the  sternum  by  a  broad  cicatrix, 
consequent  upon  a  burn  received  when  five  years  old. 

In  all  these  cases  the  deformity  partakes  of  the  same 
character,  and  if  seen  early  enough  is  to  some  extent 
amenable  to  treatment.  The  slighter  cases  depending  upon 
thumb-sucking  are  usually  treated  by  the  dental  surgeon, 
who  in  rectifying  the  position  of  the  teeth  necessarily  im- 
proves the  condition  of  the  jaw.  In  the  more  severe  cases, 
constant  support  by  an  elastic  band  making  traction  upon 
the  jaw  will  be  of  much  service,   as  in  the  cases  of  Dr, 


DEFORMITIES    OF    THE   JAWS. 


431 


Humphry  and  Mr.  Chalk.  The  cases  depending  upon  the 
contraction  of  cicatrices  can  only  be  relieved  by  treating 
the  cicatrices,  and  the  pressure  of  a  screw-collar,  worn  for 
the  purpose  of  extending  these,  will  do  much  to  restore  the 
shape  of  the  jaw,  if  the  case  is  not  one  of  too  long  standing. 
Disease  originating  within  tlie  mouth  may  lead  to  ulti- 
mate deformity  of  the  jaws ;  thus  cancrum  oris,  in  addition 
to  leading  to  closure  of  the  jaws,  as  described  in  a  pre- 
vious chapter,  may  lead  to  very  considerable  deformity  of 
the  alveoli.     A  case  of  closure  with  deformity  thus  caused, 

Fig.  202. 


successfully  treated  by  Mr.  Bernard,  of  Clifton,  has  been 
already  referred  to  (p.  403) ;  but  a  still  more  remarkable 
case  was  under  the  care  of  my  friend,  the  late  Mr.  W. 
Harrison,  to  whom  I  am  indebted  for  the  accompanying 
engravings  of  it.  The  patient,  aged  thirty-six,  had  suffered 
in  childhood  from  cancrum  oris,  which  had  destroyed  the 
greater  part  of  the  right  cheek.  His  appearance  is  shown 
in  fig.  202,  and  it  will  be  seen  that  the  lips  were  widely 
separated,  and  that  a  considerable  protrusion  of  the  alveolar 
processes  of  both  jaws,  with   their  teeth,  had  taken  place 


432  DEFORMITIES    OF    THE    JAWS. 

between  them.  Behind  this  point  the  jaws  were  united 
by  a  bridge  of  bone,  and  the  patient,  who  was  totally  unable 
to  open  his  mouth,  fed  himself  through  an  aperture  between 
the  teeth  on  the  left  side.  In  October,  1867,  Mr.  Harrison 
extracted  the  seven  teeth  which  projected,  and  reflected  the 
gums  from  the  adjacent  alveoli,  when  as  much  of  them  as 
was  thought  desirable  was   removed  with  the  bone-forceps. 

Fig.  20.3. 


The  molar  teeth,  which  had  been  driven  into  the  interior 
of  the  moutli,  were  then  extracted  with  some  difficulty, 
when  a  pillar  of  bone,  about  the  size  of  an  ordinary  lead- 
pencil,  connecting  the  alveoli,  was  brought  into  view,  but 
was  not  interfered  with.  The  gums  were  brought  together 
with  stitches,  and  the  operation  was  concluded.  The  ap- 
pearance of  the  patient  some  weeks  afterwards  is  shown  in 

fig.  203. 

The  patient  having  been  transferred  to  the  care  of  Mr. 
James  Lane,  that  gentleman  proceeded  to  perform  a  plastic 
operation  for  the  improvement  of  the  condition  of  the  lips. 
A  very  long  \/"S^^P^^  incision  was  made,  extending  from 
the  extremities  of  the  lips  (which  were  firmly  attached  to 
the  alveoli)  to  a  point  about  an  inch  in  front  of  the  ear, 


DEFORMITIES   OF   THE  JAWS. 


433 


thus  embracing  within  it  the  cicatrix  of  the  original  disease. 
The  tissues  were  freely  dissected  from  the  upper  and  lower 
jaws,  and  were  brought  together  over  the  old  cicatrix.  An 
incision^  two  inches  long,  was  made  along  the  lower  border 
of  the  jaw,  to  enable  this  to  be  done  without  too  great  ten- 
sion, and  the  parts  were  held  together  with  hare-lip  pins  and 

Fig.  204. 


sutures.     The  operation  was  perfectly   successful,  and  the 
subsequent  appearance  of  the  patient  is  shown  in  fig.  204, 

The  interesting  details  of  this  case  will  be  found  in  a 
paper  read  by  Mr.  Harrison,  before  the  Odontological 
Society,  in  May,  1868  {British  Journal  of  Dental  Science, 
May,  1868). 


F  y 


434 


APPENDIX   OF   CASES. 


Case  I. — Compoimd  Comminuted  Fractures  of  loth  Upinr  and 
Lower  Maxilla},  with  Extensive  Laceration  of  Face,  &c. — 
Recovery.  Under  the  care  of  Mr.  E.  Stamer  O'Grady, 
F.K.C.S.I.,  M.B.,  &c.,  Mercer's  Hospital,  Dublin. 

A  strong  healthy  man  was  admitted  a  few  minutes  after 
receiving  severe  injuries  l)y  the  wheel  of  his  vehicle,  in 
which  was  some  heavy  machinery,  passing  over  his  face. 
Both  upper  jaw^s  were  smashed  away  from  all  their  osseous 
attachments,  and  completely  detached  from  one  another ; 
the  left  one  being  severely  comminuted,  and  the  molar 
teeth  pinched  together  in  pyramidal  form.  The  left  side 
of  the  soft  palate,  and  for  some  distance  down  along  the 
side  of  the  tongue,  were  extensively  torn.  The  parts  here 
gaping  widely,  and  forming  a  large  chasm,  the  sides  of 
which  were  tags  of  muscular  tissue  and  tendinous  fibre. 
The  lower  jaw  was  also  broken  in  different  places,  one 
fracture  running  obliquely  down  to  the  left  of  the  incisors, 
another  branching  off  from  it,  and  breaking  away  the  portion 
of  bone  bearing  these  teeth.  There  was  also  commmuted 
fracture  of  the  mental  prominence.  The  left  ear  was  nearly 
off,  and  considerable  damage  was  done  to  the  face  generally, 
more  especially  to  the  region  of  the  nose,  which  was  fractured, 
and  the  forehead  distended  with  air,  which,  with  the  effused 
blood,  speedily  weighed  down  the  upper  eyelids,  and  totally 
blinded  the  patient.  The  upper  lip  beneath  the  nares  was 
entirely  cut  through.  Ha3morrhagc  from  the  mouth  was  free 
and  persistent ;  the  flow  coming  from  ])ehind  tlie  displaced 
teeth.  No  ligaturable  spot  could  l)e  found.  Careful  and  long 
sustained  digital  pressure  by  ]\Ir.  Finlay,  one  of  the  resident 
pupils,  failed  to  check  it,  the  comminuted  and  loosened  state 
of  the  jaw  affording  no  stay  against  which  to  exercise 
effective  pressure.  With  considerable  difficulty  the  molar 
teeth  were  wired  into  line,  and  then  a  long  strip  of  lint, 


COMPOUND    COMMINUTED    FRACTURES,    ETC.       435 

which  had  previously  been  steeped  in  an  aqueous  sohitiou 
of  perchloride  of  iron  and  dried,  was  carefully  packed  up 
behind  them.  This  stopped  the  further  loss  of  Ijlood,  which 
in  the  aggregate  had  been  great.  The  lower  jaw  was  wired 
into  position,  suitably  bandaged,  and  the  superficial  wounds 
attended  to.  Five  hours  after  the  accident,  and  as  it  so 
happened,  at  a  moment  when  Mr.  O'Grady  was  in  the  ward, 
he  suddenly  threw  his  arms  up,  and  after  a  few  paroxysmal 
efforts,  ceased  to  breathe.  Bronchotomy  was  immediately 
practised  ;  the  tube  being  opened  above  the  isthmus  of  the 
thp'oid,  and  resuscitation  soon  effected.  Shortly  thereafter 
over  a  pint  of  clotted  blood  was  vomited.  At  midnight 
respiration  was  quite  free,  and  the  eyelids  could  be  partially 
opened.  The  tracheotomy  tube,  after  ha\dng  been  experi- 
mentally corked  for  some  hours,  was  removed  at  the  begin- 
ning of  the  third  day.  Next  day  there  was  some  difficulty 
of  breathing ;  there  was  now  considerable  redness,  swelling, 
bogginess,  and  tenderness  at  the  root  of  the  neck.  This 
local  inflammatory  attack  proved  to  be  one  of  severe  type, 
attended  with  profuse  cellulitis,  and  required  numerous 
incisions  on  the  neck  and  front  of  the  thorax  to  evacuate 
the  pus  and  sloughs.  Its  course  was  attended  with  delirium 
and  much  prostration.  Twelve  days  after  the  accident  one 
of  the  dislocated  incisor  teeth  fell  out.  The  condition  of  the 
neck  was  now  impro^dng,  and  from  the  cuts  the  discharge 
was  healthy  pus.  Still  the  man  was  slow  to  recover  strength, 
it  being  three  weeks  before  he  could  sit  up.  Occasional  flying 
abscesses  continued  to  form,  and  from  one  of  these,  forty-two 
days  after  the  accident,  a  necrosed  piece  of  the  lower  jaw 
was  picked  out.  The  wires  from  the  upper  jaw  were 
removed  at  this  time  ;  union  being  good,  and  the  teeth  firm. 
No  union  had  occurred  in  the  lower  jaw,  which,  too,  had 
sedulously  been  kept  wired  and  maintained  in  good  position. 
Patient,  now  fairly  well  and  strong,  was  allowed  to  go  to  his 
home  in  the  suburbs.  He  attended  regularly  as  an  extern, 
and  sixty-one  days  after  the  accident  the  wiring  was  removed 
from  the  lower  jaw,  union  being  then  firm.  A  good  deal  of 
contraction  and  bad  shape  of  the  fauces  existed  where  the 
parts  had  been  torn.  As  time  advanced  this  toned  down, 
and  in  another  month,  during  which  two  further  abscesses 
required  opening,  the  man,  now  in  perfect  health,  was  dismissed 
from  treatment. — Medical  Press  and  Circular. 


F  F  2 


436  APPENDIX  OF  CASES. 

Case  II. — Mr.  Holmes*  Case  of  Fracture  of  the  Neck  of  the  Con- 
dyle of  the  Lower  Jaw ^  tvith  Displacement  of  the  Lower  Frag- 
ment into  the  Meatus  Auditorius  Extermis. — Serous  Discharge 
from  the  Ear. 

J.  L.,  aged  fifty,  was  admitted  into  St.  George's  Hospital  on 
July  20,  1860.  It  seemed  that  lie  had  been  sleeping  in  a 
hay-loft,  and  being  drunk,  had  walked  out  of  the  window 
during  the  night.  He  was  found  lying  on  the  ground,  and 
was  brought  to  the  hospital  at  half-past  four  A.M.  He  was 
then  sensible,  but  seemed  to  be  stupid  from  drink.  There 
were  several  cuts  about  the  face,  and  one  beneath  the  chin. 
Blood  was  flowing  from  the  right  ear.  There  was  some 
ecchymosis  about  the  right  temporo-maxillary  articulation,  and 
crepitation  was  detected  in  that  neighbourhood,  though  not  very 
distinctly.  He  was  unable  to  move  his  jaw,  and  complained 
of  intense  pain  in  trying  to  do  so.  The  mouth  was  drawn  to 
the  right  side.  The  pupils  were  natural.  On  the  following 
day  considerable  serous  discharge  was  noticed  to  flow  from 
the  ear.  In  the  evening  he  was  very  restless  and  feverish ; 
but  no  head-symptoms  were  observed.  Next  day  (the 
third)  the  discharge  continued,  mixed  with  blood,  and  there 
was  great  pain  in  the  head.  He  had  considerable  difficulty 
in  speaking.  On  the  fourth  day  from  the  accident  the 
symptoms  of  delirium  tremens  became  more  marked,  and  he 
sank  rapidly,  dying  in  the  evening.  Other  extensive  injuries 
existed  of  which  no  mention  need  be  made  here.  It  is 
sufficient  to  say  that  the  skull,  the  brain,  and  the  cerebral 
membranes  were  perfectly  healthy. 

On  examining  the  tympanum,  traces  of  blood  were  found  in 
the  mastoid  cells,  but  hardly  a  drop  in  the  tympanum  itself. 
A  probe  passed  into  the  tympanum  through  the  external 
meatus  without  resistance,  and  after  dissection  a  large  rent 
was  seen  at  tlie  upper  part  of  the  membrana  tympani.  This 
was  probably,  in  great  part,  produced  by  the  dissection.  The 
meatus  externus  was  full  of  clotted  blood,  and  serous  fluid 
could  be  seen  exuding  from  the  ear.  The  temporal  bone  was 
carefully  examined,  but  no  fracture  was  found.  The  lower 
jaw  was  fractured  in  two  places — viz.,  through  the  base  of  the 
coronoid  process,  separating  that  process  from  the  rest  of  the 
bone,  and  through  the  neck  of  the  condyle.  The  condyle 
remained  in  position,  and  the  joint  seemed  in  all  respects 
healtliy.  The  lower  fragment  was  somewhat  displaced,  and 
had   produced    laceration    of    the    meatus,    separating    the 


UNUNITED   FRACTURE   OF    LOWER  JAW,  437 

cartilaginous  from  the  osseous  portion  for  nearly  half  of  its 
circumference,  A  large  quantity  of  l3lood  lay  around  the 
fracture,  and  in  the  neighbourhood  of  the  hone  there  was 
some  fluid  of  a  sero-purulent  appearance.  The  preparation 
submitted  to  the  Society  consisted  of  three  fragments  of  the 
lower  jaw,  and  the  greater  part  of  the  temporal  bone,  showing 
the  laceration  of  the  meatus  auditorius.  In  consequence  of 
the  dissection  that  had  been  undertaken  in  order  to  open  the 
tympanum  and  mastoid  cells,  the  integrity  of  the  petrous  por- 
tion of  the  temporal  had  been  destroyed,  but  the  absence  of 
fracture  and  the  course  which  the  blood  had  taken  were  still 
shown  by  the  contrast  l^etween  the  meatus,  which  was  lined 
with  clotted  blood,  and  the  mastoid  cells  and  tympanum,  in 
which  hardly  a  trace  could  be  found. —  Transactions  of  the 
Pathological  Society,  vol.  xii. 

Case  III. —  Ununited  Fracture  and  Necrosis  of  the  Loiver  Jaw, 
tvith  Salivary  Fistida,  from  old  Gunshot  Injury — 0])eration 
— Satisfactory  Result,     Under  the  care  of  the  Author. 

James  P.,  aged  tliirty-two,  was  admitted,  August  19, 1862, 
into  the  Westminster  Hospital,  under  the  care  of  the  author, 
for  necrosis  of  the  lower  jaw. 

History. — In  March,  1860,  when  in  the  64th  Eegiment,  and 
wliilst  marching  through  Central  India,  he  was  struck  on  the 
right  side  of  the  lower  jaw  by  a  spent  bullet,  fired  by  some 
hill  robbers.  He  was  stunned  for  a  few  moments,  and  had 
hsemorrhage  for  half  an  hour.  He  went  to  the  rear,  but  was 
able  to  continue  the  march.  The  following  day  he  went  into 
camp  hosjDital,  under  the  regimental  surgeon,  at  which  time 
the  parts  about  the  wound  were  much  swollen.  The  wound 
was  bathed  with  warm  water,  and  the  swelling  was  rubbed 
with  soap  liniment.  At  this  time  he  w^as  able  to  open  his 
mouth  and  eat  on  the  left  side  without  pain  ;  but  three  weeks 
afterwards,  having  attempted  to  eat  on  the  right  side,  he  felt 
a  grating  sensation  and  much  pain,  and  told  the  surgeon  his 
jaw  was  broken  ;  but  the  surgeon  did  not  believe  him.  The 
last  molar  tooth  was  found  to  have  been  displaced  and  to  be 
lying  horizontally,  and  attempts  were  made  to  extract  it,  but 
unsuccessfully.  It  gave  him  extreme  pain,  and  the  surgeon 
then  admitted  that  the  jaw  was  splintered.  A  gutta-percha 
splint  was  now  moulded  on,  and  a  bandage  applied  for  eight 
days,  the  wound  having  by  this  time  closed.  On  April  9, 
1860,  he  was  admitted  into  the  Kurrachee   Hospital,   and 


438  APPENDIX   OF   CASES. 

another  splint  was  applied,  and  kept  on  three  or  four  days, 
when  a  large  abscess  formed.  It  was  opened,  and  a  large 
quantity  of  matter  discharged,  and  the  wound  then  healed. 
Another  abscess  began  to  form  immediately  behind  the 
opening,  and  just  below  the  original  wound ;  and  tliis  also 
was  opened  and  poulticed,  and  has  never  closed.  The 
regiment  arrived  at  Dover,  on  August  6,  1861,  and  the 
man  was  doing  duty  ;  but  the  cold  weather  coming  on,  the 
wound  inliamed  and  swelled  up  again,  and  he  was  sent  into 
Fort  Pitt,  on  May  14,  1862.  During  the  whole  of  this  time 
he  felt  a  numbness  over  the  chin  and  all  round  the  mental 
foramen.  Various  attempts  had  been  made  to  extract  the 
last  molar  tooth,  which  Dr.  Longinore  removed  with  some 
difficulty.  After  the  patient  liad  been  in  the  hospital  for 
twenty-one  days,  he  was,  on  June  26,  1862,  invalided  and 
discharged  from  the  service. 

Present  Condition. — There  is  an  open  sinus  on  the  right 
angle  of  the  jaw,  leading  down  to  dead  bone  and  into  the 
mouth,  and  he  can  blow  air  tlirough  the  aperture.  He  can 
bite  perfectly  with  the  left  side,  and  can  open  his  mouth  as 
wide  as  most  people.  He  does  not  complain  of  any  pain  in 
the  part,  and  his  general  health  is  good.  He  has  never  had 
syphilis.  A  small  piece  of  bone  has  worked  out  into  the 
mouth  since  admission.  On  looking  into  the  mouth,  a  good 
deal  of  swelling  about  the  ramus  of  the  jaw  is  seen.  The 
second  molar  tooth  is  in  situ,  but  loose. 

Opcndion,  Aug.  26. — Chloroform  having  been  adminis- 
tered, the  author  proceeded  to  enlarge  the  external  opening, 
and  removed,  with  the  gouge,  several  pieces  of  necrosed  bone. 
He  found  that  the  jaw  had  Ijeen  fractured,  that  it  had  not 
united,  and  that  the  upper  fragment  was  tilted  forwards  by 
tlie  temporal  muscle,  thus  causing  tlie  projection  in  the  mouth 
before  noticed.  The  wound  was  filled  with  lint,  and  a  com- 
press applied. 

28th. — Face  considerably  swollen,  l)ut  pain  sliglit ;  wound 
discharging  freely  ;  can  blow  air  easily  through  the  wound 
from  the  mouth. 

Sept.  10. — "Wound  has  much  decreased  in  size  ;  two  or 
three  small  particles  of  Ijone  have  worked  out  through  the 
mouth. 

20th. — The  last  molar  tooth  of  the  right  side  being  quite 
loose,  was  extracted. 

28th. — Says  that  the  opening  from  the  mouth  has  appeared 
larger  since  the  extraction  of  the  tooth,  so  that  he  is  unable 


FRACTURE    OF    THE    JAWS WIRE    8UTURE.       439 

to  hold  fluid  on  that  side  of  his  mouth  ;  external  wound  very 
much  diminished  in  size. 

Nov.  4. — The  wound  having  degenerated  into  a  small 
fistula,  and  there  being  no  evidence  of  further  disease  of  the 
jaw,  the  author  determined  to  attempt  to  close  it.  For  this 
purpose,  he  introduced  a  narrow  knife  into  the  opening,  and, 
by  rotating  it,  j^ared  the  surface,  including  the  skin,  and  then 
brought  the  edges  together  with  a  curved  needle  and  twisted 
suture,  over  which  collodion  was  applied. 

7th. — One  end  of  the  needle  having  cut  its  way  out,  it 
was  removed  altogether.  The  wound  was  not  united.  The 
edges  were  now  brought  together  with  a  strap  and  pad  and 
bandage. 

14th. — Wound  much  diminished  in  size;  the  edges  touched 
with  nitrate  of  silver. 

22nd. — No  fluid  now  passes  through  the  fistula,  and  he  says 
that  he  can  feel  with  his  tongue  that  the  internal  wound  has 
healed. 

26th. — External  wound  closed. 

Dec.  9. — Discharged  cured.  The  movements  of  the  jaw 
are  much  freer  than  they  were,  and  he  can  eat  on  the  wounded 
side  without  pain  or  inconvenience.  The  false  joint  does  not 
appear  to  affect  in  any  way  the  powers  of  mastication  or 
articulation. — Medical  Times,  January,  1863, 

Case  IV. — Fracture  of  the  Jaws — Wire  Suture.     Under 
the  care  of  Mr.  Eushton  Parker, 

A  boy,  aged  twelve,  was  brought  to  the  Stanley  Hospital  on 
September  4,  1875,  having  half  an  hour  previously  fallen 
a  depth  of  about  six  feet  into  a  neighbouring  sandstone 
quarry,  some  of  the  loose  stones  of  which  had  crushed  and 
injured  his  face.  The  left  cheek  was  raw  from  general  abra- 
sion, and  the  lower  lip  split  and  ragged  all  over  the  red 
margin.  The  left  upper  jaw  was  obviously  depressed,  its  front 
teeth  and  their  alveolar  margin  driven  in,  and  a  perceptible 
difference  of  level  between  the  hard  palate  of  this  and  the 
right  side. 

The  lower  jaw  was  fractured  at  the  first  left  bicuspid  tooth, 
the  break  passing  obliquely  downwards  and  backwards,  the 
inner  margins  of  the  fragments  being  exposed,  rendering  the 
fracture  compound.  The  displacement  here  was  considerable. 
There  was,  in  addition,  free  bleeding  from  the  right  ear. 

In  about  an  hour  later  the  jaw  was  drilled  and  wired.     He 


440  APPENDIX    OF    CASES, 

was  now  much  blanclied,  and  his  pulse  very  feeble  and  quick  ; 
the  bleeding  continued  from  the  ear,  but  he  was  quite  con- 
scious and  not  in  pain.  Intense  ecchymosis  of  the  eyelids 
had  now  come  on,  greatly  increasing  the  disfigurement.  The 
bicuspid  tooth  at  the  seat  of  fracture  was  first  withdrawn,  as 
a  precaution  to  ensure  union.  I  then  held  the  jaw  with  the 
left  hand,  and  the  liandle  of  an  Archimedean  drill  with  the 
right,  while  the  liouse-surgeon  worked  the  drill.  Two  drill- 
holes were  made,  one  in  front  of,  and  the  other  behind,  the 
fracture,  both  being  directed  below  the  le"\'el  of  the  inferior 
dental  canal,  so  as  to  avoid  wounding  the  nerve. 

The  front  drilling  was  performed  sunply  through  the  jaw 
after  turning  down  the  lower  lip ;  but  that  of  the  j)Osterior 
fragment,  being  behind  the  corner  of  the  mouth,  was  per- 
formed by  piercing  the  cheek  from  the  outside,  drilling  the 
bone  there,  and  passing  the  wire  through  bone  and  cheek  ; 
the  wire  was  then  picked  up  from  inside  the  cheek  by 
incising  the  mucous  membrane  under  which  it  lay,  the  hole  in 
the  cheek  being  then  done  with  and  left  to  lieal. 

Each  end  of  the  wire  was  then  twisted  into  a  coil  by  means 
of  the  key  devised  by  Mr.  Hugh  Owen  Thomas,  of  Liverpool, 
which  is  simply  a  steel  rod  with  a  slit  at  the  end,  the  coil 
in  each  case  lying  on  the  outside  of  the  bone,  but  inside 
the  lip  and  cheek.  In  returning  the  wire  from  the  inside 
through  the  drill  hole,  a  straight  hollow  needle  was  used  ;  this 
being  easily  introduced  from  the  outside,  and  taking  the  tip 
of  the  wire  which  is  then  withdrawn  with  the  needle.  When 
the  wire  was  twisted  up  the  apposition  of  the  fragments  was 
perfect,  and  tlie  only  subsequent  treatment  adopted  was 
frequent  washing  and  wiping  of  the  mouth  and  injured  parts. 

No  dressing  or  bandages  of  any  description  were  used,  and 
the  depression  of  the  upper  jaw  was  disregarded.  The  bleed- 
ing from  the  ear  ceased  the  same  evening,  and  the  boy  never  had 
any  particular  discomf(trt,  and  slept  well  each  night  afterwards. 

On  the  following  day  the  key  was  introduced  into  one  of 
the  coils  of  wire  to  tighten  it  up,  and  about  a  quarter  of  a  turn 
given  ;  after  wliich  the  wire  was  not  again  interfered  with 
until  withdrawn. 

He  was  kept  in  bed  about  a  week,  and  fed  on  liquid  diet 
for  about  a  fortnight,  by  which  time  distinct  union  had  taken 
place,  as  exhibited  by  an  almost  complete  absence  of  tender- 
ness on  straining  the  fragments. 

He  lost  three  upper  incisor  teeth  and  the  left  canine,  and 
their  alveoli  necrosed,  during  his  convalescence.     The  left 


SHELL   WOUND    OF   JAW.  441 

lower  second  milk  molar  was  shed  during  this  period,  and  the 
permanent  bicuspid  appeared  in  its  place. 

The  wire  was  cut  and  withdrawn  twenty-six  days  after 
being  put  in,  consolidation  being  firm,  and  some  periosteal 
callus  having  formed. 

An  abscess  formed  in  the  cheek  at  the  seat  of  fracture,  and 
left  a  sinus  leading  to  bone  ;  this,  however,  was  healed  com- 
pletely in  ten  weeks. 

His  appearance  more  than  three  months  after  the  accident 
is  somewhat  peculiar,  as  the  injury  to  the  upper  jaw  has  im- 
parted a  curious  vacant  expression  to  his  face,  the  lips,  too, 
being  a  little  apart.  Tliis  is  mainly  due  to  the  absence  of  his 
front  teeth  and  their  alveoli,  the  place  of  which  has  granulated 
up  and  cicatrised  ;  the  deformity  due  to  the  depressed  maxilla 
alone  l^eiug  now  but  slight ;  when  complete  contraction  of  the 
cicatrix  has  taken  place  he  will  be  able  to  have  a  plate 
and  some  artificial  teeth,  which  will  probably  restore  his 
natural  exj^ression.  The  lower  jaw  is  in  every  respect  satis- 
factory, strong,  and  without  any  deformity. 

Case  V. — Extensive  Injury  to  the  Jaws  hy  Shell — Secondary 
Hemorrhage — Ligature  of  Common  Carotid  Artery — Death 
from  Cholera.  By  Dr.  D.  Lloyd  Mokgan,  E.ISr.  (Notes 
by  Dr.  Birch,  E.N.) 

William  Howden,  aged  twenty-six,  a  marine  of  H.M.S. 
lHuryalus,  was  in  the  Japanese  war,  and  was  struck  on  the 
15th  of  August,  1862,  by  a  portion  of  a  ten-inch  sheU.  The 
right  side  of  the  neck  and  face  was  frightfully  shattered, 
the  wound  extending  from  the  corner  of  the  mouth  as  far 
back  as  the  zygoma  superiorly,  and  the  sterno-mastoid  a  little 
below  the  angle  of  the  jaw  inferiorly,  the  mouth  being  laid 
open.  The  body  of  the  jaw  on  the  right  side,  from  witliin 
an  inch  of  the  symphysis  to  the  angle  was  shattered.  The 
zygoma  was  fractured  in  two  places,  and  the  alveolar  process 
of  the  upper  jaw  was  crushed  at  the  roots  of  the  first  two 
molar  teeth.  The  fragments  wliich  were  loose  were  removed ; 
there  was  no  bleeding  from  the  wound,  which  was  searched 
in  vain  for  divided  vessels ;  the  jagged  edges  were  brought 
together,  and  water  dressing  was  applied. 

On  the  evening  of  the  19th,  sudden  arterial  haemorrhage 
came  on,  and  about  two  pints  of  blood  were  lost.  The 
bleeding  ceased  almost  as  suddenly  as  it  commenced,  only 
slight  oozing  continuing. 


442  APPENDIX  OF  CASES. 

20th. — Eetuni  of  bleeding  to  nearly  same  extent  as  before, 
but  ceased  under  pressure  applied  to  carotid. 

21st,  4<  A.M. — The  haemorrhage  recurred  to  an  alarming 
extent,  tlie  patient  being  almost  pulseless.  Dr.  Morgan 
proceeded  to  cut  down  upon  and  tie  the  common  carotid 
artery  above  the  omo-hyoid,  meeting  with  considerable  diffi- 
culty owing  to  the  matting  together  of  the  tissues.  There 
was  no  return  of  haemorrhage,  and  the  ligature  came  aw^ay 
safely  on  September  3,  and  the  patient  was  doing  well, 
several  small  pieces  of  the  jaws  having  come  away,  when, 
on  the  17th  of  September,  he  was  attacked  with  symptoms 
of  cholera,  and  died  at  midnight. 

Autopsy. — On  reHectiug  l^ack  the  soft  parts  from  the  cliin, 
several  fragments  of  the  lower  jaw  were  found  loose,  one 
spiculum  projecting  downwards,  and  giving  rise  to  an  external 
swelling,  and  another  containing  an  incisor  and  bicuspid 
tooth.  The  zygomatic  arch  was  fractured  at  both  extremities. 
The  lower  jaw  was  wanting  on  the  right  side  from  the  sym- 
physis to  the  ramus  ;  the  upper  jaw  was  fractured. 

The  common  carotid  was  found  to  have  been  obliterated 
about  two  inches  below  the  bifurcation,  a-mass  of  filjro-cellular 
tissue  extending  from  that  spot  to  the  bifurcation,  through 
the  upper  half  of  which  was  a  small  tortuous  canal.  A  clot 
extended  from  the  point  of  ligature  dow^l  to  the  bifurcation 
of  the  innomiuata,  and  another  clot  extended  for  three-quarters 
of  an  inch  into  the  internal  carotid  artery.  The  source  of  the 
hcemorrhage  was  not  discovered. 

Case  VI. — Necrosis  of  nearly  the  ivliole  of  the  Lower  Jaw — 
Bcmoral  of  the  Dead  Bone,  including  one  Condyle — Ec- 
covery  ivith  'perfect  Movement  of  Jaw.  Under  the  care  of 
the  AuTHOE. 

Egix'rt  H.,  aged  twenty-two,  from  Aylesbury,  was  sent  to 
Mr.  Heath  by  Mr.  Ceely  witli  necrosis  of  the  lower  jaw. 

In  August,  1868,  he  had  typhus  fever  in  Walsall  Union, 
and  during  tlie  attack  the  face  became  swollen,  and  discharged 
both  externally  and  into  the  mouth.  His  teeth  were  all 
loosened,  but  none  were  extracted.  In  December  he  was  passed 
on  to  Aylesbury,  and  came  under  under  Mr.  Ceely's  care. 

On  Feljruary  24,  1869,  i)atient  was  admitted  into  University 
College  Hospital  under  Mr.  Heath's  care.  The  right  side  of 
the  lower  jaw  was  immensely  swollen,  and  two  inches  below 
the  angle  was  a  sinus  through  which  a  probe  passed  up  to- 
wards the  base.     Another  sinus  existed  below  the  right  cnnine 


EXTENSIVE  NECROSIS  OF  LOWER  JAW.    443 

tooth,  and  there  had  been  a  third  below  the  left  angle, 
which  was  now  closed.  The  teeth  were  all  more  or  less  loose, 
and  tliere  were  several  openings  in  the  gnnis,  from  which  a 
most  offensive  discharge  passed  into  the  mouth.  The  man 
was  well  nourished  and  otherwise  in  good  health,  though  he 
had  when  a  child  suffered  from  hip  disease.  On  the  day  of 
admission,  under  chloroform,  Mr.  Heath  extracted  the  molar 
teetli  of  the  right  side  which  were  loose,  and,  having  divided 
the  gum,  extracted  a  very  large  sequestrum,  comprising  the 
right  side  of  the  body  of  the  jaw  from  the  canine  tooth  to  the 
angle,  and  containing  the  mental  foramen.  The  haemorrhage 
was  very  free,  but  was  checked  hj  plugging  the  shell  of  new 
bone  from  which  tlie  sequestrum  was  taken.  The  plugs  were 
removed  on  the  second  day,  and  the  mouth  syringed  out  daily 
with  disinfecting  lotion. 

On  March  3,  1869,  under  chloroform,  Mr.  Heath  cleared 
out  some  small  fragments  of  necrosed  bone  left  in  the  right 
angle  of  the  jaw,  and  then  proceeded  to  remove  the  necrosed 
portion  on  the  left  side,  which  extended  as  far  as  the  second 
molar  tooth.  Mr.  Heath  attempted  to  save  the  incisor  teeth, 
it  appearing  at  first  that  the  alveolus  of  that  part  of  the  jaw 
was  not  involved.  It  proved,  however,  that  the  disease  had 
affected  the  whole  thickness  of  the  bone,  and  the  teeth  were 
necessarily  sacrificed.  Upon  removal  of  the  sequestrum  there 
was  left  a  complete  framework  of  new  bone,  with  a  deep  groove 
extending  from  the  right  angle  (which  was  quite  hollowed  out) 
to  the  second  molar  tooth  of  the  left  side.  The  mouth  liled 
freely,  but  this  was  checked  as  before  by  stuffing  with  lint. 
The  patient  made  a  good  recovery,  and  was  able  to  return  to 
the  country  in  a  week,  the  discharge  having  almost  entirely 
ceased,  and  there  being  a  dee-p  groove  in  the  new  structures  of 
the  jaw  from  which  the  sequestrum  had  l)een  extracted. 

On  June  16,  the  patient  returned,  there  l^eing  a  portion  of 
diseased  bone  on  the  right  side.  This  Mr.  Heath  extracted, 
under  chloroform,  with  some  difficulty,  through  the  mouth, 
when  it  was  found  to  include  the  angle  and  a  gi-eat  part  of  the 
ramus  of  the  jaw.  From  this  operation  also  the  patient  made 
a  speedy  recovery,  and  returned  to  the  country,  and  was  not 
seen  again  by  Mr.  Heath  until  October,  when  he  returned  with 
yet  more  necrosis,  involving  the  remainder  of  the  right  ramus. 
This  was  removed  with  difficulty  on  October  30,  and  the  man 
has  not  since  suffered  from  pain  or  discharge,  so  that  it  seems 
that  the  whole  of  the  dead  bone  has  now  been  taken  away. 

Perhaps  the  most  singular  feature  in  this  c^se  is  the  fact 


444  APPENDIX   OF   CASES. 

that  the  mau  has  now  (December)  as  perfect  movement  of  the 
jaw  as  if  no  disease  had  existed,  notwithstanding  that  at  the 
last  operation  the  whole  of  the  right  condyle  was  removed  en- 
tire, with  about  a  third  of  the  ramus.  The  repair  has,  in  fact, 
been  as  complete  as  possible.  When  we  saw  the  patient  five 
weeks  after  the  last  operation,  there  was  some  fulness  and 
prominence  about  the  right  angle  of  the  jaw,  and  when  the 
mouth  was  widely  opened  the  lower  jaw  was  drawn  slightly 
to  the  right  side ;  but  otherwise  all  the  jaw  movements 
were  perfectly  performed  without  any  pain  or  inconvenience, 
a  deep  groove  in  the  gum,  reaching  from  the  right  angle  to 
the  second  left  molar,  alone  remaining  to  show  the  former 
seat  of  such  extensive  disease. — Medical  Times  and  Gazette, 
Dec.  18,  1869. 

Case  VII. — Abscess  in  the  Bight  Upper  Maxilla,  communicating 
u-ith  the  Antrum.     By  Mr.  Makgetson,  of  Dewsbury. 

Mrs.  M.,  aged  about  forty,  called  to  consult  me  about  an 
enlargement  of  the  right  side  of  her  face. 

Found  a  hard  swelhng  of  the  gums,  extending  from  the 
median  line  to  the  right  canine,  and  considerable  bulging  of 
the  palate.  She  was  wearing  a  badly  made  partial  set  of 
teeth  over  the  roots  of  the  incisors  and  left  canine  ;  the  right 
canine  was  the  only  tooth  left  in  the  upper  jaw.  Three  years 
ago  had  some  swelling  after  pain  in  right  lateral  incisor,  and 
abscess  formed  in  the  socket  of  that  tooth.  Her  medical 
attendant  tried  unsuccessfully  to  extract  the  roots.  The 
swelling  decreased  after  a  time,  but  never  disappeared 
entirely,  and  for  the  last  four  months  it  has  steadily  in- 
creased. She  has  had  no  pain  or  tenderness,  and  only 
feels  a  sort  of  heaviness,  and  is  anxious  about  the  facial 
disfigurement. 

On  attempting  to  remove  the  root  of  the  lateral  incisor,  it 
crumbled  under  the  instrument.  Trying  a  second  time,  and 
using  a  little  more  pressure,  in  order  to  seize  the  root  a  little 
higher,  the  forceps  suddenly  sHpped  upwards  and  were  buried 
to  the  joint  in  a  cavity  in  the  bone.  A  gush  of  thin  brownish 
fluid  was  the  result,  and  free  bleeding  from  the  gum  ;  there 
was  also  a  discharge  from  the  right  nostril.  Passing  up  a 
probe,  I  found  a  cavity  extending  from  the  alveolus  of  the 
right  central  incisor,  behind  the  canine,  to  the  position  of  the 
first  bicuspid — which  had  been  extracted  some  years.  At 
the  posterior  extremity  of  the  roof  of  the  cavity  there  was 


DISEASE   OF   ANTRUM    I.YVOLVrN^G  BRATN.        445 

a  pretty  large  opening  into  the  antrum,  through  which  the 
probe  passed  without  meeting  with  any  resistance.  After 
satisfying  myself  that  there  was  no  tumour  in  the  antrum, 
and  remo^^ng  a  small  piece  of  dead  bone  from  the  lower 
cavity,  I  syringed  well  with  warm  water,  and  dismissed  my 
patient. 

The  only  treatment  required,  after  the  extraction  of  the 
roots,  was  syringing  with  warm  water  for  three  or  four  days. 
No  stimulating  injection  was  used,  showing  that  tliere  was  no 
disease  in  the  antrum,  or  alteration  in  the  secretion  from  the 
lining  membrane. 

Case  VIII. — Disease  of  the  Maxillary  Antrum,  involving  the 
Brain.     By  R.  S.  M.ur,  M.D.,  F.E.C.S.E.,  Madras. 

I  was  first  called  to  see  Mr.  J.  L.,  aged  thirty  years,  on  the 
22nd  of  March,  1861.  He  complained  then,  and  for  some  days 
previously,  of  a  copious  fetid  discharge  from  the  left  nostril, 
severe  pain  in  the  left  cheek,  extending  upwards  round  the 
corresponding  orbit.  There  was  no  swelling  over  any  part 
of  the  nose  or  cheek  ;  the  third  molar  tooth  of  the  left  side 
was  loose  and  painful,  and  oozing  from  its  side  was  a  free 
fetid  discharge  the  same  as  from  the  nostril. 

Suspecting  these  symptoms  to  be  probably  produced  by 
some  mischief  in  the  maxillary  antrimi,  the  loose  tooth  was 
without  difficulty  removed,  and  with  immediate  rehef.  The 
discharge  from  the  nostril  disappeared,  and  the  pain  in  the 
cheek  and  round  the  orbit  almost  entirely  ceased. 

Four  days  afterwards  (26tli)  the  same  severe  pain  returned, 
but  of  distinctly  intermittent  character ;  there  was  still  no 
discharge  from  the  nostril  or  tooth  socket. 

On  the  following  day  (27th)  the  patient  had  a  sharp  rigor, 
followed  by  fever,  which  continued  for  some  hours,  and  the 
pain  in  the  face  and  round  the  orbit  continued  unabated, 
notwithstanding  the  local  apphcation  of  anaesthetic  anodynes. 

On  the  evening  of  the  31st,  Dr.  J.  Shaw  saw  the  case 
with  me,  and  suspected  abscess  deep  in  the  cellular  tissue 
of  the  upper  eyehd,  behind  the  eyeball ;  an  incision  was 
made  in  the  upper  eyelid  close  under  the  supra-orbital 
ridge,  which  gave  vent  to  a  discharge  of  some  sanguineo- 
purulent  matter. 

There  was  immediate  rehef  to  the  sense  of  fulness  in  the 
eye ;  the  eyeball  could  be  moved  more  easily,  though  A-ision 
was  not   perceptibly  improved.      The    patient    slept    better 


446  APPENDIX    OF   CASES. 

that  night  than  he  had  done  for  .se"\'eral  nights  previously, 
but  otherwise,  on  the  following  morning  (April  1),  his 
symptoms  were  most  unfavourable.  The  eyeball  was  enlarged 
to  nearly  double  its  natural  size,  and  was  protruding  con- 
siderably forwards,  while  the  upper  eyelid  was  again  very 
much  swollen,  and  the  lower  one  everted,  exposing  the 
chemosed  conjunctiva,  and  leaving  about  one-half  of  the  eye 
itself  uncovered  and  exposed. 

The  patient  complained  of  little  pain,  and  remained  tranquil 
up  to  eleven  o'clock  forenoon  of  April  2,  when  suddenly, 
and  without  a  single  premonitory  symptom,  he  had  a  most 
violent  convulsive  fit,  of  an  epileptic  form  and  tetanic 
character.  This  fit,  which  was  followed  by  two  others  of  the 
same  kind  on  the  same  day,  was  preceded  by  a  peculiar 
scream  or  howl,  followed  immediately  by  rigidity  of  the 
whole  body,  opisthotonos,  foaming  at  the  mouth,  and  com- 
plete unconsciousness.  These  fits  each  lasted  about  five 
minutes,  but  consciousness  did  not  return  till  some  time  after. 

This  was  the  first  indication  of  cerebral  complication.  It 
should  be  here  noted,  that  prior  to  the  first  fit,  in  consequence 
of  the  great  distension  of  the  eyeball, "and  as  no  matter  was 
foimd  in  the  incision,  which  was  made  deep  into  the  cellular 
tissue  of  the  orbit,  a  seton  was  introduced  into  the  left  temple, 
and,  subsequently  to  the  fits,  a  cantharides  blister  was  applied 
to  the  nape  of  the  neck. 

On  April  5  the  eye  continued  much  swelled,  and  some 
pus  escaped  from  the  wound  over  the  eyelid.  The  probe 
w^as  again  introduced  to  give  free  vent  to  the  matter,  but 
none  came  away.  During  this  day  the  patient  had  a  recur- 
rence of  the  same  fits  as  before,  and  while  in  one  of  them 
the  pulse  flickered  and  fluctuated  so  much  as  to  threaten 
extinction  every  moment. 

He  continued  in  the  same  condition  all  the  7th  and  up  till 
the  evening  of  April  8,  when  he  became  completely  coma- 
tose. From  this  he  never  rallied,  but  gradually  sank,  and 
died  early  on  the  morning  of  April  9,  sixteen  days  after  he 
first  consulted  me. 

Tlie  eye  during  the  last  three  days  of  his  life  remained 
unchanged  ;  a  small  quantity  of  pus  escaped  from  the  wound 
in  the  eyelid,  but  there  was  little  or  no  decrease  in  the 
swelling  of  the  globe.  The  discharge  from  the  nostril  ceased 
after  the  globe  began  to  swell,  and  that  from  the  tooth- 
socket  disappeared  after  the  tooth  was  extracted. 

The  patient  had  always  enjoyed  good  health  prior  to  his 


DISEASE  OF    ANTR.UM    INVOLVING:}    BRAIN.        447 

last  illness.  He  had  none  of  the  usual  indications  of  the 
strumous  diathesis,  and  there  was  no  reason  to  suppose  that 
lie  had  any  syphilitic  taint  in  his  constitution. 

Post-mortem  appearances. — Head  only  examined.  Purulent 
matter  in  considerable  quantity  flowed  from  the  cavity  of  the 
arachnoid,  and  from  between  the  hemispheres,  on  the  removal 
of  the  falx.  There  was  a  layer  of  more  consistent  pus  on 
the  visceral  surface  of  the  arachnoid  in  some  parts  of  both 
hemispheres,  which,  on  removal,  did  not  leave  the  arachnoid 
roughened. 

At  the  anterior  margin  of  the  left  hemisphere,  there  was 
a  rugged,  excavated,  and  ulcerated  surface,  rather  larger 
than  a  florin,  covered  with  thick  purulent  matter,  and  ap- 
pearing to  be  the  source  of  the  pus  found  in  the  arachnoid  ; 
but  on  turning  up  the  anterior  edge  of  the  hemisphere  from 
the  roof  of  the  orbit,  there  was  found  on  its  lower  surface, 
about  an  inch  from  its  anterior  extremity,  a  small  opening, 
with  dark-coloured  edges,  from  which  a  thin  serous  and 
discoloured  fluid  was  exuding.  This  opening  led  to  a  cavity 
large  enough  to  contain  a  good-sized  walnut,  lined  with  a 
dark-greenish,  investing  membrane,  of  at  least  half  a  line 
in  thickness,  wliich  could  easily  be  peeled  off  from  the  sur- 
rounding cerebral  substance. 

The  brain  was  now  removed,  and  was  perfectly  healthy. 

On  introducing  the  finger  into  the  orbit,  and  passing  it 
along  its  inner  boundary,  the  latter  was  found  diseased — 
the  ethmoid  bone  crumbling  before  the  finger,  which  passed 
readily  into  the  upper  part  of  the  nose.  Here  all  the 
osseous  structures  yielded  readily  to  the  touch  of  the  nail, 
and  portions  of  the  ethmoid  bone  were  removed  by  it  with 
great  facility. 

They  were  in  a  state  of  caries,  of  very  fetid  odour,  and 
bathed  in  pus  ;  broken-down  scrofulous  matter  on  both. 

The  contents  of  the  orbit  being  removed,  the  antrum  was 
opened  from  above,  when  its  cavity  was  found  filled  with 
a  white,  soft  substance  of  the  appearance  and  consistence 
of  firm  blancmange,  and  also  very  fetid.  This  substance, 
subsequently  examined  under  the  microscope,  was  found  to 
consist  mainly  of  tuberculous  matter,  interlaced  with  very 
delicate  fibres,  and  showing  an  abundance  of  pus-corpuscles. 
The  membrane  lining  the  antrum  was  entire,  considerably 
congested,  and  streaked  with  red  lines.  The  cavity  of  the 
antrum  did  not  appear  to  be  enlarged. — Edinburyh  Medical 
Journal,  May,  18(56. 


448  APPENDIX    OF   CASES. 


Case  IX. — Removal  of  large  Cystic-sarcoma  of  Lower  Jaw — 
Recovery.    Under  the  care  of  the  Author. 

The  patient  is  a  native  of  Cumberland,  and  has  been  a 
carter  ever  since  he  was  eight  years  old.  His  parents  are 
living  and  healthy.  When  a  child  he  suffered  from  sup- 
purating glands  in  the  neck  and  submaxillary  region,  which 
were  opened  :  otherwise  he  has  always  enjoyed  good  health. 
Never  had  syi^hilis ;  has  lived  well ;  drinks  beer  freely ;  is 
often  drunk  {i.e.,  on  an  average  once  a  week).  Has  followed 
his  occupation  up  to  the  time  of  admission.  About  six  years 
ago  he  first  noticed  a  small,  hard  swelling,  about  the  size  of  a 
marble,  situated  in  the  right  cheek,  attached  to  the  gum  and 
lower  jaw,  but  movable  under  his  fingers.  From  the  first 
it  had  an  aching  pain,  dull  and  constant.  The  tumour  con- 
tinued to  increase  in  size,  and  four  years  ago  it  was  lanced 
in  the  gum ;  it  then  began  to  discharge,  and  has  continued  to 
do  so  slightly  ever  since.  He  has  noticed  that  the  discharge 
is  more  abundant  after  drinking  much.  It  has  been  lanced 
twice  since,  and  within  the  last  six  months  it  has  been  twice 
tapped  by  Mr.  Watson,  of  Lancaster :  the  first  tapping  just 
before  Christmas ;  the  second,  five  weeks  before  admission. 
Mr.  Watson  says  that  at  each  tapping  about  four  ounces 
of  fluid  were  drawn  off.  From  the  displacement  inwards 
of  the  two  anterior  molars  and  the  second  bicuspid  tooth 
by  the  increased  growtli  of  the  mass,  these  teeth  were 
extracted  two  years  ago.  Since  Christmas  the  tumour  has 
grown  with  increased  rapidity,  and  has  become  more  tender. 
During  this  time  the  patient  says  he  has  lost  a  stone  and  a 
half  in  weight,  and  that  his  appetite  has  diminished.  The 
patient  cannot  assign  any  cause  for  the  origin  of  the  growth. 
He  has  had  no  bad  teeth  in  that  jaw.  Eemembers  having 
had  a  blow  on  the  jaw  witli  a  pitclifork  handle  before  the 
tumour  appeared. 

July  10,  1872. — The  patient  is  fairly  built,  fiorid,  and  sun- 
burnt. He  does  not  look  ill.  Tongue  clean ;  appetite  better 
than  it  has  been  ;  pulse  76,  full  and  bonneting. 

The  right  side  of  the  face  presents  a  large,  smooth,  globular 
swelling,  which  occupies  the  whole  side.  It  extends  in  front 
to  the  angle  of  the  mouth ;  behind,  to  a  distance  of  about  an 
inch  behind  the  lobule  of  the  ear,  measuring  in  this  diameter 
7^  in.  Above,  it  extends  from  the  tragus  of  the  ear  along 
the  lower  margin  of  the  orbit  to  the  side  of  the  nose  ;  below, 
on  a  level  with  the  hyoid  bone.     It  measures  from  above 


LARGE   CYSTIC-SA.RCOMA   OF  LOWER  JAW.       449 

down,  over  the  greatest  prominence,  S^  in.  The  circumference 
of  the  mass  measures  18  in.  The  right  angle  of  tlie  mouth 
is  drawn  slightly  upwards  and  outwards ;  but  the  contour  of 
the  lower  lip  is  unaffected,  and  the  contour  of  the  chin  quite 
preserved.  The  upper  part  of  the  mass  is  more  vascular  in 
appearance  than  the  lower.  On  the  under  surface  are  some 
cicatrices  from  the  abscesses  which  were  opened  when  he  was 
a  child.  The  rest  of  the  surface  of  the  tumour  is  quite 
smooth,  not  ulcerated.  Temperature  of  the  cheek,  99-7°.  The 
tumour  is  more  tender  posteriorly  than  elsewhere.  Its  lower 
two-thirds  feel  hard  and  resisting,  the  skin  being  quite 
movable  over  the  mass.  The  posterior  portion  of  the  tumour 
is  also  solidj  as  well  as  a  portion  which  extends  in  front  of 
the  ear  for  about  an  inch.  The  rest  of  the  mass  is  soft  and 
fluctuating,  evidently  containing  fluid,  and  the  upper  margin 
of  the  solid  portion  can  be  distinctly  felt  across  the  tumour ; 
inside  the  mouth  the  alveolar  border  of  the  right  side  of  the 
lower  jaw  is  much  widened,  extending  inwards,  so  as  to 
diminish  the  cavity  of  the  mouth  behind  the  first  bicuspid. 
The  second  bicuspid  and  first  and  second  molar  teeth  are 
wanting.  The  patient  says  the  third  molar  is  present ;  but  it 
is  not  visible,  nor  can  it  be  felt.  On  the  widened  alveolar 
border  is  an  ulcerated  surface,  covered  with  a  layer  of  thin 
purulent  fluid,  which  is  continually  oozing.  The  tumour 
evidently  arises  from  this  part  of  the  lower  jaw ;  for,  an- 
teriorly, a  thin  shell  of  bone  can  be  felt  continuous  with  the 
jaw  and  with  the  surface  of  the  tumour.  The  upper  jaw 
does  not  seem  to  be  implicated  in  the  growth.  The  teeth  in 
it  are  all  present ;  but  the  alveolar  border  has  been  displaced 
inwards  from  the  growth  of  the  tumour,  so  that  the  roof  of  the 
mouth  appears  contracted  (fig.  93). 

July  12. — Chloroform  having  been  administered,  Mr.  Heath 
proceeded  to  remove  the  tumour.  He  first  extracted  the  right 
canine  and  second  incisor  teeth  of  the  lower  jaw,  a  piece  of 
the  jaw  coming  away  with  the  teeth.  He  then  made  a 
vertical  incision  to  the  right  of  the  symphysis  through  the 
lip  down  to  the  base  of  the  jaw  ;  from  the  lower  end  of  this 
incision  he  cut  upwards  and  backwards  over  the  tumour 
towards  the  ear  as  far  as  one  inch  above  the  angle  of  the  jaw ; 
in  making  this  cut  he  divided  the  facial  artery.  Ligatures 
were  applied  before  the  incision  was  completed.  The  whole 
length  of  the  incision  was  about  nine  inches.  The  superficial 
tissues  were  then  dissected  off  the  tumour,  the  large  upper 
flap  being  first  raised  ;  and  the  tumour  was  carefully  shelled 

G  G 


450  APPENDIX  OF  CASES. 

out.  In  dissecting  up  this  flap  the  facial  artery  was 
again  cut  and  ligatured.  The  cyst  at  the  upper  part  of  the 
tumour  being  now  fully  exposed,  it  was  laid  open  by  a  free 
incision  extending  right  across  it,  and  about  ten  ounces  of 
fluid  escaped.  ]\Ir.  Heath  then  continued  to  separate  the 
mass  from  the  skin  at  the  lower  part,  and,  having  cleared  it 
as  far  as  the  anterior  incision,  he  sawed  through  the  jaw 
where  the  teeth  had  been  extracted.  He  then  cut  through 
the  mucous  membrane  and  muscles  attached  to  the  jaw,  and 
here  again  some  vessels  had  to  be  secured.  Having  com- 
pletely separated  the  mass,  he  attempted  to  forcibly  depress 
the  jaw  so  as  to  disarticulate  it ;  but,  the  coronoid  process 
becoming  caught  against  the  malar  bone,  he  had  to  detach 
the  process  by  the  bone  forceps.  On  depressing  the  jaw,  he 
found  that  a  small  portion  of  the  condyle  was  free  from  the 
growth.  As  he  was  proceeding  to  disarticulate,  the  remains 
of  the  lower  jaw  gave  way  just  below  the  condyle,  the 
tumour  shelling  out  from  the  expanded  bone  round  it.  The 
posterior  part  of  the  jaw  was  left  nearly  down  to  the  angle ; 
a  small  piece  of  this  was  afterwards  cut  ofl'  with  the  bone 
forceps.  About  four  ligatures  were  applied  to  bleeding 
vessels,  and  the  rest  of  the  hjemorrhage  was  arrested  by  the 
actual  cautery.  The  wound  was  then  thoroughly  sponged 
out  and  sewn  up  ;  for  the  incision  through  the  lip  hare-lip 
sutures  were  employed,  and  a  very  fine  suture  for  the 
mucous  membrane  of  the  lip,  the  rest  of  the  incision  being 
closed  by  silver  wire  sutures ;  the  whole  of  the  wound  was 
then  painted  with  collodion.  There  was  not  very  much 
blood  lost  during  tlie  operation.  The  patient  was  not 
thoroughly  under  the  influence  of  chloroform  the  greater 
part  of  the  time. 

After  removal  the  tumour  was  almost  globular  in  form.  It 
measured  3^  inches  in  diameter  at  its  widest  point.  It  was 
slightly  lobular  on  the  surface.  It  weighed  13^  oz. ;  but  at 
the  upper  and  outer  aspect  was  a  large  cyst  capable  of  con- 
taining about  ()  oz.  of  fluid.  The  lower  part  of  the  wall  of 
the  cyst  was  bony,  but  tlie  whole  of  the  upper  part  was  free 
from  bone.  The  whole  of  the  inner  wall  of  the  cyst  was 
formed  of  a  thin  layer  of  bone.  Just  anterior  to  this  large 
cyst  was  a  smaller  one  containing  about  ^  oz.  of  thick  fluid, 
in  which  was  a  large  quantity  of  cholesterine.  Its  walls 
were  Ijony  everywhere.  l>oth  cysts  were  lined  by  a  smooth 
thin  membrane.  On  the  inner  side  of  the  tumour  were  two 
openings  about  f  in.  iu  diameter,  which  had  opened  into  the 


EXTENSIVE   EPITHELIOMA    OF   LOWER  JAW.      451 

mouth.  They  communicated  with  a  large  cavity  in  the  centre 
of  tlie  tumour,  into  which  the  finger  couhl  Ije  pushed  as  far 
as  the  second  joint.  On  making  a  section  right  tlirough 
the  mass,  this  central  cavity  was  found  to  be  about  2  inches 
long.  The  inner  surface  was  very  irregularly  lobulated. 
The  lobules  varied  in  size  from  a  pea  to  a  filbert.  They 
were  covered  by  a  smooth  membrane.  The  tumour  was 
moderately  firm,  of  a  whitish  colour,  and  small  points  of 
bone  were  scattered  through  it.  On  scraping,  it  yielded  a 
whitish  fluid  mixed  with  fragments  of  the  suljstance  of  the 
tumour.  Under  the  microscope  this  was  found  to  consist 
of  a  few  spindle  cells  and  a  vast  number  of  free  oval  nuclei, 
containing  one,  two,  or  three  shining  nucleoli.  Some  of 
the  nuclei  were  perfectly  circular.  The  average  diameter  was 
about  yoVtj  inch. 

On  examining  sections  made  from  one  of  the  lobules  from 
the  central  cavity  of  the  tumour,  it  was  found  to  consist 
chiefly  of  a  dense  fibrous  tissue,  amongst  which  were  oval 
and  irregularly  shaped  spaces,  having  an  appearance  much 
resembling  acini  and  ducts  of  glands.  They  were  completely 
filled  with  oval  nuclei,  each  containing  one  or  more  bright 
shining  nucleoli.  They  were  arranged  along  the  walls  of  the 
spaces  so  as  to  look  like  epithelium^  but  they  had  not  the 
distinct  cell  and  nucleus  characteristic  of  epithelium.  The 
relative  proportion  of  the  spaces  and  fibrous  tissue  varied 
greatly.  At  some  parts  it  was  almost  firmly  fibrous,  and 
at  others  the  spaces  formed  the  greater  part  of  the  growth. 
The  patient  made  a  quick  and  uninterrupted  recovery. — 
Lancet,  March  23,  1872. 

Case  X. — Case  of  Extensive  E2oithelioma  of  the  Lower  Jaio  and 
Floor  of  the  Mouth — Removal. — Satisfactory  state  two  years 
later.     Under  the  care  of  the  Authoe. 

John  S.,  aged  sixty-eight,  plumber,  was  admitted  on  the 
9th  of  January,  1879,  with  epithelioma  of  the  left  lower  jaw 
and  contiguous  mucous  surfaces  of  the  floor  of  the  mouth  and 
cheek.  In  the  early  part  of  October,  1878,  the  patient  noticed 
that  his  three  left  lower  molar  teeth  were  loose,  and  they 
were  accordingly  extracted.  About  the  beginning  of  Novem- 
ber he  noticed,  for  the  first  time,  a  small  sore  on  the  left  side 
of  the  floor  of  the  mouth,  corresponding  in  position  to  the 
teeth  removed.  This  gradually  and  almost  painlessly  in- 
creased in  size.     The  patient  began  to  suffer  likewise  froni 

U  G  2 


452  APPENDIX   OF   CASES. 

nausea,  especially  in  the  morning.  A  medical  man  who  was 
consulted  ordered  red  wash  for  the  mouth.  Three  weeks 
later  he  began  to  apply  caustics,  which  he  did  six  or  eight 
times  altogether.  About  a  fortnight  before  admission  the 
sore  began  to  bleed,  and  continued  to  do  so.  There  was  no 
history  or  evidence  of  syphilis,  and  the  patient  alleged  he  had 
alway  been  healthy.  He  was  a  smoker.  He  did  not  know 
the  cause  of  death  of  either  of  his  parents,  both  of  whom,  he 
said,  had  lived  to  old  age.  His  brothers  all  died  at  com- 
paratively early  age,  ascribed,  by  the  patient,  to  their  un- 
healthy occupation  as  masons.  He  was  unable  to  give  an 
account  of  the  nature  of  their  last  illness. 

On  admission  he  was  a  corpulent  but  very  aniiemic  man, 
looking  younger  than  his  real  age,  and  had  general  tremors. 
He  was  losing  flesh,  because  the  condition  of  his  mouth 
allowed  him  to  take  but  little  food.  The  bowels  were  regular, 
and  the  general  health  fair.  He  suffered  from  sleeplessness, 
and  pains  about  the  affected  side  of  the  face  of  a  radiating 
and  lancinating  kind. 

On  opening  the  mouth  an  ulcerating  mass  of  new  growth 
was  observed,  involving  the  left  half  of  the  floor  of  the  mouth 
and  adjoining  alveolar  process  of  lower  jaw,  the  surface  of 
which  was  composed  of  large  vascular  granulations,  ragged 
and  covered  at  the  posterior  part  with  small  sloughs.  To  the 
feel  it  was  soft  and  extremely  tender,  extending  backwards  as 
far  as  the  ascending  ramus  of  the  jaw,  inwards  to  the  middle 
line,  and  in  front,  beyond  this,  to  the  right  as  far  as  the  right 
canine  tooth,  which  was  very  tender  when  pressed  upon, 
although  on  the  outer  side — i.e.,  between  the  gums  and  lips — 
it  was  not  evident  beyond  the  mid-line.  The  structures  at 
the  floor  of  the  mouth  were  involved  to  a  considerable  depth, 
but  the  tongue  was  free.  Externally  it  involved  the  alveolar 
process  of  the  lower  jaw  on  the  left  side,  and  extended  to  the 
junction  of  its  gingival  mucosa  with  that  of  the  cheek.  The 
teeth  of  both  upper  and  lower  jaw  were  discoloured  ;  the 
left  lower  molar  and  the  right  lower  molars  and  bicuspids 
were  absent. 

No  enlargement  of  lymphatic  glands  could  be  felt  in  the 
neck,  nor  was  there  any  induration  or  tenderness  beneath 
the  jaw.  There  was  a  sanious  fetid  discharge  from  the  growth, 
and  slight  stomatitis.  The  tongue  was  furred,  especially  at 
the  back,  and  red  at  the  edges. 

Urine  :  sp.  gr.  1018,  neutral,  high  coloured,  no  albumen  or 
sugar. 


EXTENSIVE   EPITHELIOMA    OF    LOWER   JAW.     453 

The  lieart  and  lungs  were  healthy.  Neither  spleen  nor  liver 
was  enlarged. 

On  January  23,  at  3  p.m.,  the  patient  was  put  under  the 
influence  of  chloroform,  and  Mr.  Heath  extracted  the  right 
lateral  incisor  tooth,  and  then  cut  through  the  lip  and  soft 
structures  down  to  the  lower  border  of  the  jaw.  The  jaw 
was  then  sawn  through  at  the  point  where  the  tooth  had  been 
extracted.  A  string  was  now  passed  through  the  tongue  by 
which  that  organ  might  be  drawn  out  if  necessary  in  case  of 
impediment  to  breathing  (which  did  occur  once  or  twice 
during  the  operation).  Mr.  Heath  next  divided  the  structures 
beneath  the  lower  border  of  the  jaw,  beginning  at  the  lower 
end  of  his  first  incision,  and  ending  just  in  front  of  angle  of 
jaw,  the  facial  artery  l^eing  secured  by  hare-lip  pin  ligature. 
Turning  back  the  cheek  flap  the  jaw  was  sawn  through  about 
an  inch  and  a  half  in  front  of  the  angle,  and  the  piece  of  bone 
included  between  the  two  saw-cuts,  together  with  the  greater 
part  of  the  growth  attached,  removed  by  dividing  the  soft 
parts  of  floor  of  mouth  attached  to  it.  At  this  stage  much 
haemorrhage  occurred,  chiefly  from  the  liogual  artery  and  its 
branches,  which  were  all  ligatured.  The  dental  foramen  in  the 
portion  of  jaw  left  behind  having  been  closed  with  a  spigot  of 
wood,  the  remainder  of  the  growth  was  dissected  off'  the  flap. 
The  parts  were  then  mopped  out  with  a  strong  solution  of 
chloride  of  zinc ;  all  suspicious  particles  removed  ;  the  flap 
was  brought  down  and  secured  by  four  or  five  fine  wire 
sutures,  two  hare-lip  pins  and  twisted  sutures  being  employed 
to  secure  the  lip,  with  an  additional  suture  of  fine  silk  at  the 
upper  part  at  the  verge  of  its  mucosa.  At  the  posterior  part 
of  the  wound  a  small  opening  was  left,  through  which  the 
end  of  the  ligature  applied  to  the  facial  artery  was  allowed 
to  protrude,  acting  instead  of  a  drainage-tube.  The  edges  of 
the  wound  were  finally  painted  over  with  collodion,  and 
covered  with  dry  lint,  and  the  patient  put  to  bed.  The  string 
in  the  tongue  was  allowed  to  remain,  and  kept  out  of  the 
mouth  in  case  its  use  should  become  necessary. 

On  examining  the  growth  removed  it  presented  all  the 
naked-eye  appearance  of  an  ulcerating  epithelioma,  involving 
the  alveolar  process  as  far  back  as  the  last  molar  tooth,  while 
forwards  it  was  co-extensive  with  the  excision.  It  spread 
outwards  to  the  adjacent  part  of  the  cheek,  but  involved 
only  the  mucosa,  and  not  the  deeper  structures.  Inwards  it 
reached  along  the  floor  of  the  mouth  as  far  as  mid-line.  The 
tongue  was  not  involved.     The  posterior  section  of  the  face 


454  APPENDIX   OF   CASES. 

showed  two  questionaLle-lookiiig  spots  of  probably  an  exten- 
sion of  the  growth. 

The  patient's  pulse  became  irregular  and  feeble  after  the 
operation,  and  he  appeared  somewhat  collapsed ;  but  brandy- 
was  administered,  and  he  had  ice  to  suck.  There  was  little 
trouble  with  the  tongue,  and  he  slept  well  during  the  night. 
Next  morning  the  pulse  was  still  feeble,  but  regular,  and  the 
patient  seemed  to  be  in  good  spirits. 

On  the  2-lth,  patient  complained  of  headache.  He  had 
slept  fairly  during  the  night.  The  pulse  was  very  weak,  92  ; 
temperature  99" ;  respiration  24.  As  he  had  not  taken  his 
food  well,  an  enema  of  beef-tea  and  brandy  and  eggs  (of  each 
one  ounce)  was  administered.  The  mouth  was  carefully 
washed  out  with  a  good  quantity  of  warm  solution  of  Condy's 
fluid  lotion.     Discharge  not  very  offensive. 

On  the  25th  he  had  slept  fairly  well.  He  complained  of 
pains  in  the  lower  lip  and  up  the  left  side  of  the  face.  The 
pulse  was  still  very  weak,  9Z  ;  temperature  99°.  The  parts 
were  well  syringed  out. 

On  the  27th  the  patient  was  looking  quite  bright.  The 
parts  were  doing  very  well.  The  sawn  s-urfaces  of  the  bone 
could  be  seen  covered  with  granulations. 

On  the  29th  the  temperature  was  normal,  and  the  patient 
had  thoroughly  recovered  from  the  effects  of  the  operation. 
The  discharge  from  the  mouth  drained  through  the  lower 
opening,  and  was  only  slightly  offensive. 

From  this  time  the  patient  made  a  rapid  and  steady  re- 
covery, and  was  discharged  on  February  21  to  go  to  East- 
bourne. He  returned  in  March  with  the  mouth  quite  healed. 
In  November,  1880,  the  patient  visited  the  hospital  in  per- 
fect health,  having  grown  stout  and  strong  for  his  age.  The 
mouth  was  perfectly  sound,  the  gap  in  the  jaw  being  filled  by 
firm,  dense  cicatrix,  covered  with  healthy  mucous  membrane, 
the  right  side  of  the  jaw  being  drawn  inwards  by  the  action 
of  tlie  muscles,  as  is  usual  in  cases  of  division  of  the 
mandible. — Lancet. 

Case  XI. — Epithelioma  of  the  Antrum — Pneumonia — Death. 
Under  the  care  of  the  Auxnoii. 

li.  M.,  aged  fifty-nine,  a  shoemaker,  was  admitted  on 
May  30,  1879.  At  the  beginning  of  the  previous  month 
he  had  noticed  that  his  right  nostril  was  obstructed  ;  a  week 
or  two  afterwards  the  lower  lid    of   the   right  eye  became 


EPITHELIOMA    OF    THE    ANTUUM.  455 

inflamed,  and  a  swelling  which  commenced  here  rapidly 
extended  over  the  right  cheek.  About  this  time  a  painful 
swelling  of  the  hard  palate  appeared,  and  the  patient  con- 
sulted a  dentist,  who  extracted  a  tooth.  Shortly  afterwards 
he  applied  at  the  hospital.  His  brother  was  stated  to  have 
died  of  cancer  of  the  kidney.  The  other  members  of  his 
family  were,  so  far  as  he  knew,  healthy. 

He  was  a  pale  but  well-nourished  and  well-preserved  man 
for  his  age,  though  he  had,  he  stated,  lost  flesh  latterly. 
Temperature  varied  from  99°  to  100°  E.  He  complained  of 
a  feeling  of  stuftiness  in  his  jaw,  but  of  no  pain. 

The  skin  of  the  right  side  of  the  face  was  reddened, 
cedematous,  and  tender,  and  the  cheek  was  projected  out- 
wards by  the  tumour  beneath  it.  The  right  eyelids  were 
closed  and  cedematous,  but  could  be  opened  slightly,  dis- 
playing chemosis  of  the  conjunctiva,  a  clear  cornea,  and  a 
somewhat  sluggish  iris.  The  right  nostril  was  obstructed, 
and  there  was  a  purulent  discharge  from  it ;  the  nasal  duct 
on  the  right  side  also  appeared  to  be  obstructed,  giving  rise 
to  overflow  of  tears.  To  the  touch  the  tumour  gave  the  idea 
of  a  soft  solid  rather  than  of  fluid.  Most  of  the  right  half  of 
the  hard  palate  was  absorbed,  a  soft  elastic  swelling  occupy- 
ino;  the  roof  of  the  mouth,  the  mucous  membrane  of  the 
latter  being  congested  and  swollen.  The  teeth  of  the  upper 
jaw  were  carious  or  absent,  but  the  alveolar  process  was 
neither  displaced  nor  softened.  Owing  to  the  resistance  of 
the  patient,  an  examination  of  the  posterior  nares  could  not 
be  made.  The  lymphatic  glands  in  the  posterior  triangle  of 
the  neck  were  enlarged,  but  free  from  tenderness.  The 
mouth  could  not  be  opened  to  its  full  extent,  and  speech 
was  slightly  affected.  The  tongue  was  broad,  pale^  and 
marked  by  the  teeth. 

On  the  31st  a  fine  trocar  with  canula  was  inserted  into  the 
swelling  on  the  roof  of  the  mouth,  and  a  few  drops  of  stink- 
ing pus  evacuated.  The  opening  made  by  the  trocar  w^as 
subsequently  enlarged^  and  a  drainage-tube  was  passed  into 
the  antrum. 

It  soon  became  evident  that  the  growth  was  malignant, 
and  as  the  man's  condition  became  worse  daily,  removal  of 
the  upper  jaw  offered  the  only  chance  of  prolonging  his  life. 
This  was  accordingly  done  on  June  -A.  The  floor  of  the 
orbit  was  taken  away,  but  it  was  impracticable  to  wholly 
extirpate  the  growth  in  this  direction,  as  the  orbital  struc- 
tures  were   infiltrated       The   somewhat  free  bleeding  was 


456  APPENDIX   OF   CASES. 

restrained  Ly  the  actual  cautery,  and  the  cavity  of  the  wound 
was  stuffed  with  strips  of  lint  soaked  in  a  strong  solution  of 
chloride  of  zinc. 

The  growth  appeared  to  have  commenced  in  the  antrum, 
the  w^alls  of  the  latter  l)eing  partially  absorbed,  the  anterior 
almost  wholly,  thereby  allowing  invasion  of  the  orbit,  the 
mouth,  and  the  pharynx.  Several  pieces  of  dead  bone, 
surrounded  by  offensive  pus  and  debris  of  broken-down 
growth,  were  found  in  its  cavity,  thus  accounting  for  the 
inflammatory  condition  of  the  superjacent  skin,  and  the 
purulent  discharge  from  the  mouth  and  nostrils.  In  other 
parts  the  growth  was  of  a  yellowish  colour,  translucent, 
gelatinous,  and  vascular.  Several  ordinary  soft  gelatinous 
polypi  were  extracted  from  the  right  nostril  during  the 
ojDeration. 

In  sections  taken  from  the  margin  of  the  growth  near  the 
gum,  the  microscope  showed  cylinders  of  epithelium  cells, 
irregular  in  form  and  sinuous  in  outline,  sometimes  anas- 
tomosing, set  in  a  stroma  made  up  of  fibrous  tissue  and 
spindle-shaped  cells.  Epithelium  "nests"  were  observed 
here  and  there,  but  these  were  few,  small,  and  ill-developed. 
The  papillai  of  the  mucous  membrane  covering  the  gum, 
where  the  latter  was  infiltrated,  were  hypertrophied.  The 
histological  characters  of  the  growth  appeared  to  correspond 
with  those  of  the  "  epitheliome  tubule "  of  Cornil  and 
Eanvier. 

On  June  ]  3  pneumonia  was  present  at  the  base  of  the 
right  lung,  and  on  the  following  day  friction  sounds  were 
audiljle  over  the  affected  area.  The  edges  of  the  skin  wound 
had  united,  except  at  the  inner  angle  of  the  orbit. 

On  the  16th  there  were  dulness,  extremely  weak  breath 
sounds,  diminished  vocal  fremitus,  and  resonance  to  the 
angle  of  the  right  scapula,  with  bronchial  respiration  above. 
Tlie  lymphatic  glands,  which  had  become  larger  and  very 
tender  in  the  riglit  posterior  triangle,  had  diminished  in  size 
after  treatment  with  belladonna  and  poulticing. 

On  the  18th  the  physical  signs  of  pneumonia  at  the  left 
base  became  evident,  and  the  general  condition  of  the  patient 
worse,  though  he  wanted  to  "  be  up  and  about."  The  foetor 
from  the  cavity  of  the  wound  w'as  now  almost  intolerable, 
and  one  or  two  sloughs  had  separated. 

From  this  time  the  chest  symptoms  increased  in  severity, 
and  he  died  on  June  26. 

Necropsy  (by  Mr.  Barker)  twenty-Jive  hours  after  death. — 


EPITHELIOMA   OF   THE   ANTHUM.  457 

Eigor  mortis  well  inaikcd.  Body  well  nourished.  The 
serum  in  the  pericardium  was  normal  in  amount  and 
characters.  The  heart  was  somewhat  enlarged,  and  rigor 
mortis  was  well  marked;  a  good  deal  of  fat  was  noticed, 
chiefly  on  the  anterior  surface.  The  superficial  veins  were 
somewhat  loaded.  The  right  auricle  contained  firm  post- 
mortem clot.  The  right  ventricle  was  also  engorged  with 
clot^  part  of  this  having  evidently  formed  during  several 
hours  before  death.  The  left  ventricle  was  firmly  contracted, 
and  contained  a  small  quantity  of  tough  coagulum.  The 
cardiac  valves  were  healthy.  The  left  lung  was  extremely 
emphysematous  anteriorly,  and  posteriorly  it  was  covered 
with  recent  lymph,  hardly  adherent.  There  were  six  ounces 
of  serum  in  the  left  pleural  cavity.  The  inferior  lobe  was 
considerably  congested,  and  some  small  portions  were 
collapsed.  Section  showed  general  congestion,  and  grey 
hepatization  with  softening  at  numerous  points,  but  the  lung 
was  not  gangrenous.  The  bronchi  were  intensely  congested 
in  patches  down  to  the  small  ramifications,,  and  full  of  dirty 
brown  sero-mucous  fluid.  The  right  lung  was  adherent  to 
a  large  extent  of  the  ribs,  particularly  over  the  lower  lobe, 
and  by  more  recent  lymph  above.  A  large  abscess  opened 
on  removing  lower  lobe  from  chest  wall.  This  abscess, 
occupying  a  large  portion  of  lower  border  of  upper  lobe, 
upper  border  of  lower  lobe,  and  extending  deeply  into  the 
substance  of  the  lung,  was  a  ragged,  ill-defined  space,  full 
of  black,  very  fetid,  broken-down  lung  tissue,  and  was  sur- 
rounded by  blackened,  sloughing,  very  soft  lung  tissue. 
The  bronchi,  as  in  the  left  lung,  were  intensely  congested, 
increasingly  so  towards  the  finer  ramifications,  and  full  of 
foul  sero-pus.  The  bronchial  glands  were  much  enlarged  at 
root  of  both  lungs.  The  tongue  was  covered  with  a  thick 
covering  of  foul  material,  apparently  dropping  down  from 
the  roof  of  the  mouth.  There  were  enlarged  papilla3  at  the 
base,  the  size  of  millet  seeds,  raised,  pedunculated,  and  deeply 
pigmented.  The  oesophagus  was  normal.  The  mucous  mem- 
brane of  the  larynx  and  trachea  was  inflamed  throughout. 
There  was  a  quantity  of  grey  mucus  in  the  ventricles  of  the 
larynx.  The  anterior  surface  of  hard  and  soft  palate  was 
covered  with  foul,  tenacious  pus.  The  operation  cavity  ex- 
tended back  beyond  orbit  to  the  pterygoid  fossa  and  upwards 
to  sphenoid  bone.  The  septum  of  the  nose  was  carious,  and 
giving  way.  The  orbit  and  eyeball  had  not  been  particu- 
larly injured  by  the  operation.     The  liver  was  apparently 


458  APPENDIX    OF   CASES. 

normal.  There  was  no  post-mortem  staining  in  the  great 
vessels,  nor  extravasation  in  the  mucous  membrane  of  the 
intestines. — Lancet. 

Case  XII. — Large  Osteosarcoma  of  the  Lower  Jciio — Bemoval 
— Death.     Under  the  care  of  the  Author. 

AV.  T,,  aged  thirty-two,  was  admitted  into  University 
College  Hospital,  Nov.  13,  1867,  with  an  enormous  tmnour 
of  the  lower  jaw.  About  eleven  years  before  he  had  a  severe 
pain  in  the  right  jaw  resembling  toothache,  and  after  some 
little  time  he  perceived  a  small  hard  swelling  about  the  size 
of  a  nut  just  below  the  right  canine  tooth,  which  was  not 
decayed,  nor  were  any  of  the  teeth  in  its  immediate  vicinity 
diseased.  This  swelling  continued  about  the  same  size  for 
five  or  six  years,  during  the  latter  part  of  which  time  it  was 
entirely  free  from  pain.  Four  years  ago  it  began  to  enlarge, 
and  two  years  afterwards  he  was  thrown  from  a  cart  and  fell 
on  his  face,  when  he  had  profuse  bleeding  from  the  gums. 
The  tumour  now  grew  rapidly,  spreading  along  its  anterior 
surface,  and  involving  the  whole  of  the  right  side  of  the  jaw. 
About  twelve  months  ago  it  began  to  involve  the  left  side  of 
the  jaw,  and  extended  up  to  the  angle.  He  had  been  seen  by 
various  medical  men  at  his  native  place,  and  also  by  one 
London  hospital  surgeon,  and  the  question  of  an  operation 
had  been  discussed,  but  nothing  had  been  done.  Two  years 
before,  one  quack  Ijurnt  the  inside  of  his  mouth  with  acid,  and 
another  put  a  white  ointment  upon  the  surface  of  the  tumour, 
which  caused  the  skin  to  give  way  at  the  point  where  the 
protrusion  appeared.  About  a  year  before  admission,  the 
portion  of  the  tumour  near  the  right  angle  of  the  jaw  rapidly 
increased,  and  in  a  short  time  the  skin  gave  way,  and  a 
quantity  of  offensive  pus  was  discharged,  but  there  was  no 
diminution  in  the  swelling.  Latterly,  owing  to  the  difiiculty 
in  swallowing,  he  had  been  able  to  take  little  but  milk  and 
brandy,  and  this  in  small  quantities  at  a  time,  so  that  he 
had  become  much  reduced  in  strength.  His  family  had  all 
been  healthy  and  long-lived. 

On  admission,  the  patient  presented  an  extraordinary 
appearance,  the  mouth  and  all  the  lower  part  of  the  face  being 
occupied  by  an  enormous  tumour.  The  measurements  of  this 
were  as  follows : — Lrom  the  lobule  of  one  ear  round  the  chin 
to  the  lobule  of  the  other  ear,  19^  inches;  from  the  border 
of  the  lower  lip  across  the  chin  to  the  pomum  Adami,   13 


LARGE  OSTEO-SARCOMA   OF   LOWER  JAW.         459 

inches  ;  from  the  angle  of  the  jaw  across  to  the  same  point 
on  tlie  opposite  side,  14  inches.  When  the  man  was  sitting 
the  tumour  rested  upon  the  top  of  the  sternum  ;  but  it  moved 
freely  when  he  opened  and  closed  the  mouth.  Between  the  lips, 
of  which  the  lower  was  much  stretched,  so  that  the  circum- 
ference of  the  mouth  measured  9^  inches,  there  was  a  red, 
granulating  mass  of  disease,  which  came  in  contact  with  the 
upper  lip ;  but  wdien  the  mouth  was  opened^  a  space  inter- 
vened through  which  a  second  mass,  covered  with  the  mucous 
membrane  of  the  floor  of  the  mouth,  could  be  seen  almost  in 
contact  with  the  roof  of  the  cavity,  and  completely  hiding  the 
tongue.  Between  these  two  masses  some  of  the  teeth  could 
be  felt  and  seen.  Fig.  161,  taken  from  a  photograph,  shows 
the  patient  wdtli  liis  mouth  shut.  From  beneath  the  cheek 
on  the  right  side  a  foul,  yellowish  discharge  constantly  exuded. 
An  inch  below  the  lower  lip  was  a  large  red,  fimgous  mass 
covered  with  healthy  granulations ;  this  extended  to  the  lower 
border  of  the  tumour,  and  the  skin  was  adherent  around  it. 
On  the  right  side,  just  below  the  angle  of  the  jaw,  there  was 
another  sflialler  fungous  projection ;  but  the  skin  on  the  left 
side  w^as  perfectly  healthy,  though  much  stretched.  The 
right  ramus  of  the  jaw  could  not  be  defined,  though  the  angle 
could  be  distinctly  perceived.  The  articulation,  however,  was 
not  involved.  The  tumour,  though  overlying  the  neck,  in  no 
degree  involved  its  tissues,  and  there  were  no  enlarged  glands 
either  below  the  jaw  or  in  the  neck.  On  the  left  side  the 
whole  of  the  ramus  and  angle  could  be  clearly  made  out,  the 
disease  stopping  short  of  the  latter  point. 

From  the  time  of  his  admission  the  patient  was  well  fed 
with  strong  beef-tea,  milk,  eggs,  and  brandy ;  and  consider- 
ably improved  in  appearance.  Mr.  Heath^s  colleagues 
agreeing  with  him  as  to  the  advisability  of  an  operation,  tliis 
was  undertaken  on  Nov.  20,  1S67.  The  patient  being 
seated  in  a  chair,  Mr.  Clover  administered  chloroform  at  first 
with  the  ordinary  mask,  and  during  the  operation  with  a 
smaller  one,  enclosing  only  the  nose.  As  soon  as  the  patient 
became  partially  unconscious  he  was  carefully  secured  in  the 
chair  with  bandages,  and  his  head  was  held  firmly  against 
the  breast  of  an  assistant.  Perfect  anaesthesia  having  been 
induced,  Mr.  Heath,  standing  on  the  right  hand  of  the  patient, 
divided  the  lower  lip  in  the  median  line,  and  carried  the 
incision  round  the  right  side  of  the  fungous  protrusion  to 
•the  lower  extremity  of  the  tumour.  The  skin  was  then 
rapidly  dissected  back  with  the  assistance  of  Mr.  Marshall, 


460  APPENDIX   OF   CASES. 

who  took  up  the  vessels  of  the  flap.  Eeturning  to  the 
middle  line,  Mr.  Heath  made  a  second  incision  on  the  left 
side  of  the  fungus,  meeting  the  former  one  above  and  below, 
and  dissected  back  the  skin  off  the  tumour,  as  far  as  the  jaw. 
The  bone  being  isolated  with  the  assistance  of  Mr.  Erichsen, 
the  second  molar  tooth  was  drawn,  and  a  narrow  saw  applied 
at  that  point ;  but  before  complete  division  was  effected  the 
weight  of  the  tumour  caused  it  to  break  away.  As  had  been 
pre-arranged,  Sir  H.  Thompson  then  grasped  the  tongue, 
which  was  now  seen  for  the  first  time,  and  transfixed  the  tip 
with  a  stout  needle  and  ligature,  by  which  it  wa.s  held  until 
the  operation  was  concluded.  On  dividing  the  mucous  mem- 
brane beneath  the  tongue,  a  large  lobulated  mass  came  into 
view  imbedded  among  the  sublingual  muscles ;  and  this 
being  dragged  forward,  the  muscles  were  divided  close  to  the 
tumour,  and  one  or  two  bleeding  vessels  were  promptly 
secured  by  Mr.  B.  Hill.  The  tumour  being  then  turned  over 
to  the  right  side,  Mr.  Heath  carried  the  knife  upwards,  so  as 
to  clear  the  coronoid  process,  which  was  healthy ;  but  this 
appeared  to  be  driven  forward  against  the  malar  l^one, 
and  tightly  jammed,  so  that  forcible"  traction  made  on  the 
tumour  failed  to  clear  it.  Grasping  the  process  itself  with 
the  lion  forceps,  Mr.  Heath  succeeded,  however,  in  wrenching 
it  out,  when  the  condyle  of  the  jaw,  also  healthy,  immediately 
came  forward  without  any  dissection.  A  little  dissection 
round  the  posterior  margin  of  the  tumour  now  completely 
disconnected  it,  and  it  was  removed.  About  half  a  dozen 
bleeding  vessels  were  now  tied,  none  of  them  of  large  size, 
the  two  facial  arteries  having  been  preserved  uncut.  Finding 
the  bone  on  the  left  side  where  the  tumour  had  broken  away 
rough  and  irregular,  Mr.  Heath  sawed  it  cleanly  through, 
close  in  front  of  the  wisdom  tooth. 

There  was  now  an  enormous  gap  ;  the  fauces,  tongue,  and 
front  of  the  larynx  being  fully  exposed,  and  the  flap  of  skin 
on  each  side  being  pendulous  and  superabundant.  The  right 
was  somewhat  ragged,  owing  to  the  perforation  which  liad 
taken  place,  and  also  owing  to  its  being  so  adherent  to  the 
tumour  that  it  had  been  perforated  at  one  or  two  points ;  Mr. 
Heath  therefore  removed  a  ]>ortion  of  it,  adapting  the 
opposite  flap  to  it.  The  lip  was  then  l)rought  together  with 
three  hare-lip  pins  and  a  twisted  suture,  and  the  remainder 
of  the  incision  was  held  together  with  four  silver  sutures, 
placed  some  distance  apart  so  as  to  allow  discharge  to  escape. 
The  thread  holding  the  tongue  was  next  secured  to  the  hare- 


LARGE   OSTEO-SARCOMA    OF    LOWER   JAW.       461 

lip  pins,  so  as  to  bring  the  apex  of  it  close  to  the  lip  ;  and 
some  lint  was  placed  in  the  large  cavity,  and  a  bandage 
externally,  so  as  to  check  oozing  and  maintain  the  shape  of 
the  part.  The  patient  was  then  carried  to  bed.  Not  more 
than  three  onnces  of  blood  were  lost. 

Half  an  hour  after  the  operation  the  patient  had  some 
brandy  by  the  mouth,  and  one-third  of  a  grain  of  morphia 
was  injected  beneath  the  skin.  He  dozed  during  the  after- 
noon, but  was  well  supplied  with  beef-tea  and  brandy  both 
by  the  mouth  and  per  rectum.  He  had  a  second  dose  of 
morphia  at  night,  and  got  some  sleep,  being  warm  and 
comfortable,  and  with  a  fair  pulse. 

On  the  two  following  days  the  patient's  condition  was  as 
comfortable  as  could  have  been  hoped  for ;  he  took  plenty  of 
nourishment  and  stimulants  by  the  mouth,  and  also  had 
nutrient  enemata. 

On  the  evening  of  the  third  day  his  breathing  aud  pulse  be- 
came more  rapid,  and  he  had  a  slight  rigor.  Mr.  Heath  now 
removed  the  ligature  holding  the  tongue,  which  was  giving 
him  some  inconvenience,  and  ordered  him  quinine  in  ten- 
grain  doses. 

On  the  23rd  his  condition  was  more  satisfactory  again.  The 
pledgets  of  lint  in  the  chin  were  removed,  and  the  wound 
well  washed  out  with  Condy's  fluid.  He  passed  a  comfortable 
day,  and  on  Sunday  (fifth  day)  he  was  apparently  gaining 
ground,  and  was  well  enough  to  write  his  want  of  some  stout 
upon  a  slate,  and  took  plenty  of  nourishment.  In  the  even- 
ing, however,  he  suddenly  became  worse,  the  pulse  failing 
and  the  skin  becoming  cold  ;  and  notwithstanding  the  most 
solicitous  attention  on  the  part  of  the  house-surgeon,  Mr. 
Shoppee,  he  died  early  on  Monday  morning  (sixth  day). 

At  a  post-mortem  examination,  all  the  viscera  were  found 
healthy,  and  there  was  no  evidence  of  pyipmia.  The  wound 
had  so  contracted  that  the  outline  of  the  face  was  quite 
restored.  The  skin  at  one  point  was  a  little  discoloured,  as 
by  a  bruise. 

The  tumour  weighed  4  lb.  6  oz,,  and  was  a  good  example  of 
fibro-cellular  growth,  springing  up  between  and  expanding  the 
plates  of  the  lower  jaw.  The  disease  extended  from  the  junc- 
tion of  the  body  with  the  ramus  of  the  left  side  to  half-way 
up  the  ramus  of  the  right  side.  The  right  condyle  was 
perfectly  healthy,  and  the  coronoid  process  had  been  broken 
off  in  the  operation,  Mr,  Heath  showed  the  preparation  at 
the  Pathological  Society  on  Dec.  3,  and  a  wax  model  of  it  in 


462  APPENDIX   OF   CASES. 

the  recent  state  has  been  pLiced  in  the  Museum  of  University 
College.— Lancet,  Dec.  21,  1867. 

Case  XIII. — Case  of  Symmetrical  Enlargement  of  hotli  sides 
of  the  Lowtr  Jaw — (Myeloid  ?)  Under  the  care  of  the 
Author. 

William  Henry  Hogan,  aged  seven  and  a  half,  was  brought 
to  me,  Feb.  12,  1867,  by  Mr.  C.  J.  Fox,  with  remarkable 
enlargement  of  both  sides  of  the  lower  jaw.  "VSHien  a  year 
and  a  half  old  the  mother  first  noticed  an  enlargement,  first 
of  one  side  (right  ?),  and  then  of  both,  which  has  been 
gradually  increasing.  He  has  never  complained  of  any  pain, 
but  had  a  good  deal  of  difficulty  with  his  teeth.  He  was 
rickety  in  his  legs,  and  was  at  Ormond  Street  Hospital  for 
some  time. 

He  is  now  a  well-nourished  boy,  with  a  remarkably  broad 
face,  due  to  the  symmetrical  development  of  a  tumour  on 
each  side  of  the  lower  jaw,  involving  the  posterior  half  of  the 
body  on  each  side.  The  tumours  are  smooth  on  the  outer 
and  lower  part,  but  slightly  nodulated  at  the  upper.  Within 
the  mouth  they  come  up  to  the  level  of,  but  do  not  encroach 
upon,  the  teeth.  He  has  cut  his  permanent  first  molars  and 
incisors.  The  temporary  canines  and  molars  are  still  present, 
and  somewhat  decayed. 

April  3. — He  came  to  University  College  Hospital.  Ordered 
ung.  iodin.  co.  to  apply  to  one  side.  The  boy  attended  for  a 
short  time  at  the  hospital  without  improvement,  and  then 
ceased  to  come. 

In  September  I  saw  him,  and  found  that  both  tumours  had 
consideral)ly  increased,  and  I  persuaded  his  parents  to  send 
him  into  the  hospital,  where  he  was  admitted  on  Sept.  9, 1  867. 
A  photograpli  and  cast  were  now  taken  (fig.  170). 

O'peraiion,  Sept.  11. — I  made  an  incision  over  the  right  or 
larger  tumour,  and  having  divided  and  tied  the  facial  artery, 
exposed  and  scraped  the  periosteum  off'  the  tumour.  It  was 
bony  externally,  but  felt  spongy  on  pressure.  AVith  a  narrow 
saw  I  then  removed  the  most  prominent  portion,  which  cut 
very  easily ;  then  a  second  slice,  and  afterwards,  with  the 
bone  forceps  and  gouge,  removed  as  much  of  the  semi- 
cartilaginous  structure  as  I  could  without  interfering  with  the 
teeth  or  o])ening  the  mucous  membrane.  As  the  surface  of 
the  bone  bled  freely,  it  was  touched  lightly  with  the  cautery, 
and  the  wound  was  Idled  with  lint.     The  growth  appeared  to 


MEDULLARY   SARCOMA    OF   LOWER   JAW.        463 

be  an  enchondroma,  expanding  the  outer  plate  and  under- 
going ossification,  but  is  pronounced  myeloid  by  Mr.  Bruce. 
Tlie  inner  plate  of  the  jaw  was  perfectly  even,  and  at  the  end 
of  the  operation  not  more  than  the  normal  thickness  of  jaw 
remained. 

The  wound  suppurated  healthily,  and  soon  contracted,  the 
boy  being  about  again  in  a  few  days. 

Oct.  2. — I  removed  the  growth  on  the  left  side  in  the  same 
manner  as  Ijefore.  This  growth  appeared  of  precisely  the 
same  character  as  the  other.  The  boy  made  a  rapid  recovery, 
and  was  discharged  with  the  wounds  nearly  healed  on 
Oct.  10. 

The  boy  came  to  me  in  December  quite  well,  and  a  second 
photograph  (fig.  171)  was  then  taken.  He  continues  well  at 
the  present  time. 

Case  XIV. — Medullary  Sarcoma  of  Lower  Jaio  in  a  Child — 
Tioo  successfid  Operations — Return  of  the  Disease — Death, 
Under  the  care  of  the  Authoe. 

Miss  M.  E.,  aged  five,  was  sent  to  me  by  Mr.  Edward 
Eandall,  of  Finsbury  Square,  on  Sept.  9,  J  867,  with  a  tumour 
of  the  lower  jaw.  She  was  the  tenth  of  a  family  of  eleven 
healthy  children,  and  her  parents  are  strong  and  robust.  She 
was  fat  and  well-nourished,  though  thinner  than  she  had 
been,  and  in  good  health  until  the  last  week  in  July  (seven 
weeks  before),  when  her  mother  noticed  that  the  second 
temporary  molar  tooth  on  the  right  side  was  raised  above  the 
others,  and  the  gums  looked  swollen.  Her  mother  took  out 
the  tooth,  which  was  quite  loose :  but  the  swelling  increased, 
and  the  first  permanent  molar  became  loose,  and  was  extracted 
by  Mr.  Cole,  of  Ipswich.  She  was  under  the  care  of  Mr. 
Mumford,  of  Ipswich,  who  used  nitrate  of  silver  lotion  with- 
out benefit,  since  the  growth  continued  to  increase  rapidly,  so 
that  she  has  been  unable  to  eat  solid  food  for  a  fortnight. 

The  whole  of  the  lower  jaw  on  the  right  side  was  con- 
sidtu'ably  enlarged,  and  on  opening  the  mouth,  a  large, 
irregular,  reddish  mass  was  seen  filling  up  all  the  cheek  on 
the  right  side,  the  extent  of  which  it  was  impossible  to 
define.  The  tumour  had  a  semi-elastic  feel,  and  there  were 
apparently  no  enlarged  glands.  There  could  be  no  question 
as  to  the  propriety  of,  and  necessity  for,  immediate  operative 
interference,  which  I  arranged  to  undertake  on  the  following 
day. 


464  APPENDIX    OF   CASES. 

On  Sept.  10,  1867,  the  patient  being  under  tlie  influence 
of  chloroform,  I  got  my  finger  into  the  mouth,  and  then 
ascertained  that  the  ja.w  was  completely  involved  in  the 
tumour,  the  elastic  feeling  being  communicated  through  the 
bone.  I  divided  tlie  lower  lip  in  the  median  line,  and  carried 
the  incision  round  the  border  of  the  tumour  to  the  level  of 
the  lobule  of  the  ear.  I  then  dissected  back  the  flaps,  and 
having  divided  the  facial  artery,  tied  it.  Having  extracted 
a  loose  tooth,  I  then  sawed  through  the  jaw  immediately  to 
the  right  of  the  symphysis,  and  detached  the  tissue  on  the 
inner  side.  On  making  traction,  the  tumour  came  away, 
leaving  a  rough  irregular  piece  of  the  jaw  and  a  small  portion 
of  the  tumour  behind.  These  I  subsequently  extracted, 
including  the  condyle  and  coronoid  process,  which  latter 
broke  off  and  was  removed  separately.  The  internal  maxillary 
artery  was  not  wounded,  and  there  was  no  great  hoBmorrhage, 
four  ligatures  being  aj^plied  and  cut  short.  The  lip  was 
brought  together  with  two  hare-lip  pins,  and  the  remainder 
of  the  wound  closed  by  wire  sutures,  a  silk  suture  being  put 
in  the  red  of  the  lip.  Collodion  was  painted  over  all.  No 
further  dressing  was  applied.  The  child  rallied,  and  took 
some  brandy-and-water.  In  the  afternoon  she  was  quite 
comfortable  and  the  pulse  was  good.  There  was  a  little 
oozing  from  the  wound.  In  the  evening  she  had  had  some 
sleep,  and  had  taken  a  little  soup.  She  drank  water  fre- 
quently. There  was  no  bleeding.  The  tumour  proved  to  be 
of  soft  consistence,  and  had  destroyed  all  the  body  of  the 
jaw,  and  a  portion  of  the  ramus ;  the  condyle,  coronoid 
process,  and  upper  portion  of  the  ramus  being  healthy.  The 
point  of  section  of  the  bone  was  healthy,  and  close  to  it 
were  the  canine  and  first  temporary  molar.  In  the  upper  and 
posterior  part  of  the  growth  was  the  crown  of  the  second 
permanent  molar,  carried  quite  out  of  position.  To  the  naked 
eye  the  tumour  presented  a  loose  fibroid  appearance.  Mr. 
Bruce  kindly  examined  a  portion  microscopically  for  me,  and 
reported  numerous  fibres,  with  here  and  there  development  of 
cells,  seemingly  medullary. 

Sept.  11. — She  had  had  a  comfortable  night.  The  mouth 
syringed  out  with  Condy's  fluid  three  times.  The  child  took 
some  milk  and  soup,  and  was  quite  comfortable  all  day. 

13. — Child  quite  comfortable  and  happy,  and  takes  liquid 
food  well.     I  removed  the  hare-lip  pins. 

14. — I  removed  the  sutures.  The  wound  was  healed  except 
at  the  junction  of  the  vertical  with  the  horizontal  incision, 


MEDULLARY  SARCOMA   OF  LOWER  JAW.         4G5 

where  there  is  a  minute  opening.     The  patient  to  be  dressed 
and  get  up  to-morrow. 

23. — She  went  home  to  the  country  quite  well,  with  the 
exception  of  one  spot  at  the  angle  of  the  cicatrix,  which  still 
discharged  slightly. 

Oct.  31. — I  heard  that  slie  was  quite  well. 
26. — The  child  was  brought  to  town  on  account  of  a  return 
of  the  growth.  The  mother  says  she  first  noticed  something 
wrong  on  the  22nd,  when  there  was  a  small  lump  in  the  mouth. 
This  grew  very  rapidly,  and  Mr.  Mumford  advised  her  coming 
up  at  once. 

I  found  a  mass  within  the  mouth  on  the  right  side,  nearly 
as  large,  and  of  precisely  the  same  appearance,  as  the  former 
growth.  It  involved  a  portion  of  the  jaw  left,  and  ex- 
tended to  the  canine  tooth  on  the  left  side,  the  incisors 
being  loose.  The  cicatrix  was  sound  except  at  the  junction 
of  the  vertical  with  the  horizontal  incision,  where  the  skin 
was  ulcerated  and  there  was  a  fungous  protrusion  of  the 
size  of  a  cherry.  I  explained  the  serious  nature  of  the  case 
to  the  parents,  and  said  that  an  immediate  operation  was 
the  only  hope,  as,  if  left,  the  growth  would  rapidly  fungate 
and  destroy  the  child,  and  they  consented  to  the  operation 
proposed. 

On  Oct,  27,  1867,  I  divided  the  lip  and  opened  up  the  old 
cicatrix  to  a  great  extent,  surrounding,  however,  the  portion 
involved  in  the  fungus.  I  then  dissected  back  the  flap,  and 
found  the  growth  extended  to  what  would  have  been  half  way 
up  the  ramus.  I  isolated  it,  and  then  dissected  back  the  left 
half  of  the  lip.  I  next  removed  the  first  molar,  and  sawed 
the  jaw  close  in  front  of  the  second  molar.  Having  put  a 
string  in  the  tongue  for  safety,  I  then  divided  the  sublingual 
muscles,  and  got  the  growth  and  piece  of  jaw  away  entire. 
Two  or  three  large  vessels  were  tied,  principally  under  the 
tongue,  and  a  few  small  ones.  I  washed  the  entire  wound 
carefully  with  a  solution  of  chloride  of  zinc  (forty  grains  to 
the  ounce),  brought  the  lip  together  with  two  hare-lip  pins, 
and  the  remainder  of  the  wound  with  sutures,  and  then 
fastened  the  string  attached  to  the  tongue  to  the  upper  pin  in 
the  lip.  The  child  bore  the  operation  very  well.  In  the 
evening  she  was  cold  and  restless,  but  rallied  with  the  use  of 
hot  bottles  and  a  little  brandy. 

Oct.  28. — Patient  had  had  a  good  night,  and  was  asleep 
when  I  saw  her  at  nine  o'clock,  and  warm  and  comfortable. 
She  passed  a  quiet  day,  taking  a  good  deal  of  milk  and  a 

H   H 


466  APPENDIX    OF   CASES. 

little  wine.     She  was  a  little  distressed  by  the  ligature  in  the 
tongue. 

31. — I  removed  the  hare-lip  pins  and  three  of  the  stitches, 
leaving  those  near  the  angle  of  the  wound  for  the  present,  A 
little  pus  was  pent  up  in  the  upper  part  of  the  old  cicatrix, 
which  I  evacuated. 

Nov.  1. — I  removed  the  remaining  stitches.  The  wound 
was  healing  well,  except  at  the  point  where  the  skin  was 
implicated  and  removed,  and  there  it  gaped. 

3. — The  child  was  up  and  dressed.  She  was  able  to  close 
her  lips  and  move  her  tongue  very  satisfactorily.  She  takes 
her  food  fairly,  and  has  sucked  a  chicken-bone. 

She  continued  to  improve  rapidly,  and  by  the  10th,  when 
she  returned  to  the  country,  the  wound  was  perfectly  healed 
with  the  exception  of  a  small  spot  where  the  portion  of  skin 
had  been  removed.  She  had  perfect  control  over  her  tongue 
and  lips,  and  could  move  the  tissues  of  the  chin  very  satis- 
factorily. There  was  no  appearance  of  any  return  of  the 
growth  at  this  date. 

Dec.  16. — I  heard  from  the  father  that  the  child  was  per- 
fectly well,  and  that  there  was  no  appearance  of  return  of 
the  growth.  He  sent  me  her  photograph," from  which  fig.  174 
was  taken,  to  show  how  little  deformity  resulted  from  the 
double  operation. 

On  Jan.  8,  1868,  I  heard  from  Mr.  Mumford  that  the 
disease  had  reappeared  at  the  symphysis,  and  also  in  the 
masseteric  region  on  both  sides,  there  being  loss  of  appetite, 
exhaustion,  and  general  irritability  of  system.  The  poor 
little  patient  lingered  for  a  month,  and  died  on  Feb.  9,  just 
five  months  after  I  first  saw  her. 

Case  XV. — Epithelioma  of  the  Tongue,  involving  the  Lower 
Jaw — Removal  of  the  Growth  and  three  inches  of  the  Lower 
Jaw — Recovery.     Under  the  care  of  the  Author. 

E.  J.,  agerl  fifty-two^  was  admitted  Sept.  21,  1875. 
He  was  unable  to  move  his  tongue,  and  saliva  trickled  down 
his  cliin ;  articulation  was  very  indistinct ;  he  was  quite 
unable  to  chew,  but  could  swallow  fluids  readily ;  the  breath 
was  very  offensive.  The  front  teeth  of  both  jaws  were 
worn  down  and  decayed,  and  all  the  teeth  in  the  lower  jaw 
were  very  loose.  The  gums  on  the  left  side  of  the  lower  jaw 
were  swollen,  thickened,  and  irregular,  the  surface  being 
covered  with  firm,  solid  granulations ;  this  tissue  extended 


EPfTHELlOMA   OF   THE   TONGUE.  4G7 

between  the  teeth,  into  the  floor  of  the  mouth,  and  to  the 
tip  of  the  tongue,  which  was  fixed  to  the  lower  jaw,  being 
blended  with  this  growth  on  the  gums.  The  growth  in  the 
gums  did  not  extend  beyond  the  middle  line.  Under  the 
right  angle  of  the  jaw  there  was  one  enlarged  hard  gland  ; 
on  the  left  side  there  was  a  mass  of  hard  tender  glands. 
The  patient  complained  of  pain  in  the  lower  jaw,  and  of  a 
very  severe  shooting  pain  and  tenderness  in  the  occipital 
region.  This  latter  pain  was  so  severe  as  to  make  him 
writhe  in  great  agony  at  times.  The  patient  was  thin,  looked 
worn  out  with  pain,  and  expressed  himself  willing  to  undergo 
any  operation  for  relief.  The  history  he  gave  was  that  in 
January,  1874,  he  noticed  one  of  the  glands,  under  the  jaw 
on  the  right  side  become  tender  and  swollen,  and  a  few  days 
after  a  sore  appeared  under  the  left  side  of  the  tongue,  which 
soon  went  away;  he  also  had  an  ulcerated  throat  at  this 
time.  The  gland  was  painted  with  iodine,  and  became  con- 
siderably smaller  and  ceased  to  trouble  him,  but  in  September 
following  it  swelled  again  and  broke,  discharging  pus.  About 
this  time  (twelve  months  before  admission)  he  noticed  diffi- 
culty in  articulation,  his  tongue  being  stiff' ;  this  rapidly  got 
worse,  and  at  Easter,  1875,  his  tongue  was  quite  fixed  to  the 
jaw.  He  then  went  into  St.  Bartholomew's  Hospital,  where  a 
part  of  the  tongue  was  removed,  which  greatly  relieved  him 
for  a  time,  but  he  soon  began  to  get  worse  again,  and  then 
was  sent  into  University  College  Hospital.  He  stated  that 
he  had  been  a  great  smoker,  generally  using  a  clay  pipe.  He 
had  been  quite  unable  to  take  solid  food  for  a  year  before 
admission.  No  history  of  syphilis,  tubercle,  or  cancer.  He 
was  ordered  spoon  diet,  four  eggs,  and  four  ounces  of  brandy. 
Hypodermic  injections  of  morphia  were  given  for  relief  of  pain. 
On  September  29  Mr.  Heath  proceeded  to  operate.  The 
patient  was  placed  under  cliloroform,  and  the  incisor  canine, 
and  first  bicuspid  teeth  were  extracted ;  two  pairs  of  clamp 
forceps  were  applied  to  the  under  lip  about  three  inches 
apart,  so  as  to  compress  the  coronary  vessels,  and  a  vertical 
incision  along  the  middle  line  was  made  down  the  lip  and 
continued  to  the  hyoid  bone ;  the  healthy  integuments  were 
dissected  back  from  the  jaw  on  each  side,  and  the  bone  was 
sawn  through  on  each  side  an  inch  and  a  half  from  the 
sjmiphysis.  The  wire  of  the  galvanic  ecraseur  was  then 
applied  round  the  mass  thus  loosened,  which  was  drawn 
forwards  by  vulsellum  forceps,  and  included  nearly  the  whole 
of   the  tongue  and  all  the  sublingual   tissues.      For   eight 

H  H  2 


468  APPENDIX    OF   CASES. 

minutes  a  low  current  was  passed,  which  was  then  increased 
a  little,  the  whole  process  occupying  twelve  minutes.  A 
piece  of  whipcord  was  passed  through  the  stump  of  the 
tongue,  which  was  gently  drawn  forwards  and  sponged  with 
perchloride  of  iron.  The  edges  of  the  wound  were  then 
brought  together  by  three  hare-lip  sutures,  and  a  fine  silk 
thread  through  the  mucous  membrane.  The  lower  part  of 
the  wound  was  left  open  to  serve  as  a  drain ;  the  whipcord 
ligature  was  fastened  to  one  of  the  pins  to  prevent  the  tongue 
falling  back.  A  hypodermic  injection  of  one-quarter  of  a 
grain  of  morphia  was  given,  and  the  patient  was  then  carried 
back  to  bed. 

The  patient  passed  a  good  niglit,  sleeping  a  great  deal. 
At  4  A.M  and  at  7.30  a.m.,  an  enema  of  egg,  beef-tea,  and 
brandy  was  administered.  A  good  deal  of  saliva  and  blood- 
stained serum  escaped  through  the  opening  into  the  floor  of 
the  mouth.  Next  morning  the  temperature  was  99°;  pulse 
72,  regular,  and  fairly  strong ;  he  said  that  the  pain  at  the 
back  of  the  head  was  less.  He  was  fed  through  a  catheter 
passed  into  the  oesophagus  every  two  hours  during  the  day,  and 
had  two  nutrient  enemata  at  night,  but  afterwards  he  was 
fed  only  every  four  hours,  taking  six  ounces  of  brandy  in  the 
twenty-four  hours.  He  complained  of  a  painful  swelling 
under  each  angle  of  the  jaw. 

On  October  1  a  swelling  as  large  as  half  an  orange  was 
noticed  over  the  manubrium  ;  it  pitted  on  pressure,  had  a 
distinct  edge,  not  tender,  and  was  movable  over  the  bone. 
The  tongue  was  unfastened  from  the  lip,  but  the  whipcord 
was  left  in  the  tongue  for  a  few  days  longer,  to  enable  the 
patient  to  draw  it  forward  when  he  was  fed  and  whenever 
he  felt  a  choking,  which  usually  came  on  when  he  lay  down. 
At  night,  as  he  was  found  to  be  weaker,  brandy  was  increased 
to  nine  ounces.  On  Oct  3  the  two  upper  pins  were  removed 
from  the  lip,  and  strapping  applied  across  the  jaw  and  lip. 
The  stump  of  the  tongue  was  covered  by  a  black  eschar,  and 
on  the  tonsils  and  anterior  pillars  of  the  palate  was  a  white 
exudation.  There  was  a  free  discharge  of  saliva  and  turbid 
foul-smelling  fluid  through  the  drain  under  the  chin ;  the 
patient  wore  an  oakum  l)ib  to  catch  this.  There  was  con- 
siderable swelling  on  each  side  of  the  neck  below  the  jaw, 
and  the  swelling  was  tender  and  very  painful.  The  mouth 
was  washed  out  with  Condy's  fluid  several  times  a  day,  and 
the  sloughs  painted  with  glycerine  of  carbolic  acid.  Next 
day  the  lowest  pin  was  removed,  and  the  incision  in  the  lip 


EPITHELIOMA   OF   THE   TONGUE.  469 

was  found  to  be  entirely  healed,  except  at  the  lowest  part, 
which  was  purposely  left  open. 

Oct.  4. — Temperature  98-5°;  pulse  80,  much  stronger. 
The  swelling  over  the  sternum  had  almost  entirely  disap- 
peared.    The  pain  in  the  head  was  as  had  as  ever. 

For  the  next  ^veek  the  patient  slowly  improved  ;  the  slough 
and  exudation  cleared  off  the  tongue  and  mouth  ;  the  swelling 
in  the  neck  gradually  subsided  and  became  less,  as  did  also 
the  pain  in  the  head  ;  the  temperature  was  not  above  the 
normal.  As  the  Condy's  fluid  failed  to  keep  the  mouth  sweet, 
it  was  syringed  out  with  a  dilute  solution  of  terebene,  which 
was  followed  by  a  most  marked  improvement  in  this  respect. 
After  the  4th  the  nutrient  enemata  were  discontinued. 

On  Oct.  11  it  is  noted  that  he  was  Ijetter,  with  less  pain 
in  throat  and  head,  and  that  he  looked  more  cheerful ;  the 
wdiole  of  the  stump  of  the  tongue  was  free  from  slough ;  a 
little  slough  was  still  adherent  to  the  surfaces  of  the  bone ; 
the  ends  of  the  bone  had  approximated  a  good  deal,  and  on 
the  15th  were  only  half  an  inch  apart.  After  Oct.  16  the 
pain  in  the  head  disappeared,  and  only  very  occasionally 
returned  slightly ;  he  began  to  pick  up  his  strength  fast, 
slept  well,  was  cheerful,  but  complained  of  pain  behind  the 
thyroid  cartilage  when  the  catheter  was  passed;  pressure 
over  the  thyroid  also  gave  pain,  and  a  hard  tender  lump 
under  each  angle  of  the  jaw  troubled  him.  He  had  poultices 
applied  to  these  on  Oct.  20,  which  relieved  him  very  much, 
so  that  on  the  36th  it  was  noted  that  no  lump  was  to  be  felt 
on  either  side,  and  that  he  was  quite  free  from  pain  except  in 
the  pharynx.  On  Oct.  29  the  two  pieces  of  the  jaw  were  in 
contact,  though  not  united ;  there  was  still  slight  discharge 
through  the  opening  into  the  mouth,  but  this  healed  up  by 
Nov.  4. 

On  Nov.  8  the  patient  was  sent  to  Eastbourne,  and 
returned  to  London  on  Dec.  11,  when  he  was  seen  at  the 
hospital.  He  was  very  cheerful,  and  very  pleased  with  the 
result  of  the  operation.  He  was  able  to  drink  out  of  a  feeder, 
and  swallow  without  difficulty.  The  two  pieces  of  the  jaw 
were  in  close  contact,  and  only  very  slight  movement  could 
be  obtained  between  them.  Patient  could  make  himself 
understood,  though  his  articulation  was  very  indistinct. 
The  chin  was  behind  the  upper  jaw,  but  the  disfigurement 
was  not  very  conspicuous.  There  was  no  recurrence  of  the 
growth,  and  no  enlarged  glands  under  the  jaw.  He  had  had 
no  return  of  the  occipital  pain. 


470  APPENDIX  OF    CASES. 

The  gi'owtli  was  examiued  by  Mr.  Gould,  and  found  to  be 
undoubted  epithelioma,  cylindrical  processes  of  large  oval 
fleshy  epithelial  cells  being  seen,  without  any  of  the  ordinary 
concentric  "  globes"  of  cells,  though  in  the  above-described 
cylinders  a  concentric  arrangement  of  some  of  the  cells  in 
the  middle,  approaching  that  of  the  "globes,"  was  found. 
This  tissue  was  found  under  the  tongue,  just  extending  up 
into  it ;  in  the  gums,  and  extending  back  quite  to  the  line  of 
removal.     This  patient  was  perfectly  well  in  Nov.  1883. 

Case  XVI. — Eiyithelioma  involving  the  Chin  and  Lower  Jaw — 
Removal  of  Growth  hy  section  of  hone  and  galvanic  ^craseur, 
loithout  opening  the  mouth — Recovery.  Under  the  care  of 
the  AuTHOE. 

T.  E.,  aged  fifty-five,  a  fisherman,  admitted  Nov.  6, 
1875.  In  February,  187^,  he  had  an  epitheliomatous  growth 
on  the  lower  lip  removed  at  the  Monmouth  Hospital,  and  he 
recovered  completely  from  the  operation.  But  twelve  months 
ago — November,  1874 — he  noticed  a  small  hard  lump  under 
the  lower  jaw,  to  the  left  of  the  symphysis';  this  lump  gradu- 
ally increased  in  size,  and  in  August,  1875,  it  ulcerated  at 
one  spot ;  poultices  were  then  applied,  but  more  ulcers  ap- 
jDeared.  From  that  time  the  growth  rapidly  increased,  and 
was  the  seat  of  constant  pain. 

On  admission,  the  patient  was  a  dark,  healthy-looking, 
strong  man,  though  he  stated  that  he  had  lost  fiesh  lately. 
There  was  a  rounded  tumour  fixed  to  the  left  side  of  the 
body  of  the  lower  jaw,  about  the  size  of  a  small  cocoa-nut, 
measuring  six  inches  by  five  and  a  half,  extending  two  and 
a  half  inches  to  the  right  and  three  and  a  half  inches  to  the 
left  of  the  middle  line,  reaching  down  to  the  hyoid  bone. 
Most  of  the  skin  over  the  tumour  was  adherent  to  it,  but  it 
was  free  at  the  edge  ;  the  surface  was  lobulated,  firm,  and 
elastic ;  and  on  the  under  part  there  were  six  openings  in 
the  centre  of  projecting  nodules,  from  which  a  stinking  fluid 
escaped.  There  was  a  linear  cicatrix  on  the  left  side  of  the 
lower  lip.  No  part  of  the  growth  could  be  detected  from  the 
mouth  ;  the  alveolus  of  the  jaw  was  not  enlarged.  There 
was  no  dyspnoea  nor  dysphagia. 

Nov.  10. — Tlie  patient  was  put  under  the  influence  of 
chloroform,  and  Mr.  Heath  proceeded  to  remove  the  tumour. 
He  first  made  a  curved  incision  over  the  back  of  the  tumour 
beyond  the  line  where  the  skin  was  adherent,  and  dissected 


EPITHELIOMA  OF   THE   LOWER   JAW.  471 

this  off  the  tumour  quite  readily.  He  then  united  the  ends 
of  this  incision  by  a  straight  cut  along  the  body  of  the  jaw. 
The  body  of  the  jaw  to  which  the  tumour  was  attached  was 
then  sawn  through  below  the  alveolus,  and  without  wound- 
ing the  mucous  membrane  of  the  mouth.  An  additional  piece 
of  bone  was  then  removed  from  the  left  angle  of  the  jaw 
with  the  bone  forceps.  The  galvanic  ^craseur  was  then 
applied  in  the  lines  of  incision,  and  the  mass  removed  in 
nine  minutes.  The  tissue  about  the  hyoid  bone  was  white 
and  opaque,  and  was  therefore  freely  cauterized  with  the 
heated  ecraseur.  The  submaxillary  and  sublingual  glands 
and  the  hyo-glossus  muscles  were  freely  exposed  in  the 
wound,  and  looked  healthy.  The  wound  was  washed  out 
with  solution  of  zinc  chloride,  twenty  grains  to  the  ounce, 
and  lint  dipped  in  this  was  applied,  and  kept  in  place  by 
cotton-wool  and  a  bandage. 

The  patient  slept  well  through  the  night,  being  perfectly 
free  from  pain,  but  only  able  to  swallow  liquids ;  the  next 
morning  his  temperature  was  100°  F. ;  pulse  96.  In  the 
evening  the  lint  was  removed  from  the  wound,  and  a  dressing 
of  carbolized  oil  applied.  His  temperature  gradually  fell, 
and  on  Nov.  15  it  was  98-3° ;  pulse  84.  The  submaxillary 
gland  and  the  tissue  about  the  hyoid  bone  were  seen  to  be 
sloughing ;  the  upper  part  of  the  wound  was  granulating  ; 
complained  of  headache.  The  next  two  days  an  oakum 
fomentation  was  applied  to  hasten  the  separation  of  the 
sloughs,  and  on  Nov.  18  the  surface  was  quite  clean  except 
over  the  submaxillary  gland,  and  the  headache  quite  gone. 
On  the  22nd  the  wound  was  dressed  with  red  lotion ;  the  last 
slough  had  come  away ;  the  wound  was  two-thirds  its 
previous  size.  Patient  could  swallow  solid  food  well.  On 
the  26th  five  skin-grafts  were  put  on.  On  Dec.  2  twelve 
more  were  put  on  ;  the  granulation  was  much  slower  over 
the  site  of  the  submaxillary  gland  than  elsewhere.  On  Dec.  8 
the  wound  was  about  one-third  the  size  it  was  originally; 
the  granulations  were  pale  and  flabby,  edges  firm  and  rather 
callous  ;  to  be  dressed  with  a  solution  of  nitrate  of  silver, 
two  grains  to  the  ounce. 

The  wound  continued  to  heal  well,  and  the  patient  gained 
strength  and  lost  all  pain,  which  had  not  returned  since 
the  operation.  There  was  no  appearance  of  any  recurrence 
of  the  growth  several  weeks  after  the  operation.  The  patient 
went  home  on  Dec.  23  with  the  wound  nearly  healed. 

Examination  of  Tumour  (by  Mr.  Gould). — "  The  tumour  is 


472  APPENDIX   OF   CASES. 

very  tirinly  adherent  to  the  section  of  the  body  of  the  jaw, 
but  the  bone  looks  healthy,  the  line  of  it  being  unbroken. 
On  cutting  into  the  under  surface  of  the  tumour,  a  cavity 
as  large  as  an  ordinary  apple  is  opened,  full  of  fetid  ichorous 
fluid,  with  irregular  walls  in  which  are  six  sinuses.  Ex- 
amined microscopically,  the  growth  is  seen  to  be  a  typical 
example  of  globular  epithelioma  ;  this  tissue  extends  quite 
to  the  lower  edge  of  mass  removed  (by  hyoid  bone),  but 
is  half  an  inch  from  the  surface  in  front  (where  attached  to 
jaw).'; 

This,  though  a  formidable-looking  case,  was  a  remarkably 
favourable  one  for  operation,  the  disease,  although  extensive, 
involving  none  of  the  lymphatic  glands  at  the  angle  of  the 
jaw  or  in  tlie  neck.  By  sawing  off  the  chin,  without  opening 
the  mouth,  the  whole  of  the  bony  attachment  of  the  growth 
was  isolated,  and  the  subsequent  removal  of  the  soft  tissues 
down  to  the  hyoid  bone  with  the  galvanic  ^craseur  was 
entirely  bloodless.  The  patient  made  a  thoroughly  good 
recovery,  and  it  was  hoped  had  been  efi'ectually  relieved,  at 
least  for  a  long  time. 

The  disease  recurred  and  the  patient  died  some  months 
after. 


INDEX 


Abscess  after  fracture  .... 
„        of  jaw      ..... 
„        of  antrum         .... 
Adams,  Mr.  W.,  on  cysts  of  antrum 

,,        Dr.  R.,  on  cysts  of  lower  jaw  . 
Alveolus,  fracture  of      ...         . 
Amaurosis  from  diseased  antrum  . 
Ankylosis  of  temporo-maxillary  joint   . 
Antrum,  diseases  of 
„  suppuration  in 

„         dropsy  of 
„  cysts  of   . 

,,  epithelioma  of 

;,  polypus  of 

,,  falling  in  of     . 

Articulation,  temporo-maxillary,  diseases  of 
Author's  case  of  fractured  alveolus 

,,  necrosis  of  lower  jaw 

„  hyperostosis  of  jaw     . 

;,  dentigerous  cyst 

„  cystic  sarcoma  of  lower  jaw 

„  mnltilocular  cystic  tumour 

„  odontoma    . 

,,  hypertrophy  of  gums 

,,  epulis  .... 

,,  tumonr  of  palate 

,,  epithelioma  of  gums  . 

,,  „  antrum 

„  fibroma  of  upper  jaw 

,,  enchondroma  of  upper  jaw 

,,  osteoma  ,,        ,,     . 

,,  round-cell  sarcoma  of  upper  jaw 

,,  epithelioma  „  „ 

„  ivory  exostosis  of  lower  jaw 

„  spindle-cell  sarcoma  of  lower  jaw 

„  myeloid  of  both  sides  ,,         ,, 

„  chondro-sarcoma  ,,         „ 

„  ossifying  sarcoma  „         ,, 

,,  medullary  sarcoma  ,,        „ 


PAGE 

..  20 
.  99 
.  159 
.  172 
.  199 
1,  17,  66 
.  148 
.  413 
.  152 
.  159 
.  168 
.  171 
.  267 
.  174 
.  177 
.  412 
.   17 

118,  128 

.  149 

192 

203,  210 

206,  207 
.  221 
.  230 
.  241 

249,  253 
.  256 
.  257 
.  267 
.  269 
.  278 
.  305 

309,  312 
.  341 
.  348 
.  360 
.  362 
.  365 
.  370 


474 


INDEX. 


Author's  case  of  epithelioma  of  lower  jaw   . 
„  „  of  chin    . 

„  „  of  gland  adherent  to  jaw 

„  Esmarch's  operation  for  closure 

„  closure  of  jaws  treated  with  shields 

„  disease  of  temporo-maxillary  joint 

„  hyi^ertrophy  of  neck  of  condyle 


Bean's  interdental  splint 
Beaumont,  Mr.,  enchondroma  of  lower  jaw 
Boinet,  M.,  post-mortem  examination  after  Esmar 
Broca,  M.,  on  odontomata      .... 
Bryant,  Mr.,  necrosis  of  inter-maxillary  bones 
Butcher,  Mr.,  on  cysts  of  lower  jaw 

„         ,,  vascular  tumour  of  upper  jaw 

Canceb,  osteoid,  of  upper  jaw 

„      of  upper  jaw    ..... 
„      of  lower  jaw      .... 
Cannon-ball,  injury  to  jaws  by 
Canton,  Mr.,  myeloid  tumour  of  upper  jaw 
Cap  for  fractured  jaw    . 
Caries  of  jaw         ..... 
Cartilaginous  tumours  of  ujiper  jaw    . 

,,  „  lower  jaw 

Cattlin,  Mr.,  on  the  antrum  . 
Chalk,  Mr.  0.,  deformity  of  jaw   . 

,,  ,,       reproduction  of  teeth    . 

Chin,  silver 

Chondro-sarcoma  of  upper  jaw 
„  „  lower  jaw 

Closure  of  the  jaws       .... 
Coates,  Mr.,  myeloid  tumour  of  upper  jaw 

,,         „      epithelioma  of  lower  jaw  . 
CoUis,  Mr.,  enchondroma  of  upper  jaw 
Complications  of  fractured  jaw  .  . 
Condyle,  fractured  neck  of     . 
Congenital  dislocation  .... 
Cork  wedges  for  fractured  jaw 
Couper,  Mr.,  case  of  old  dislocation 
Craven,  Mr.,  medullary  sarcoma  of  upj^er  jaw 

,,         ,,       myeloid  of  lower  jaw 
Curling,  Mr.,  ejjithelioma  of  i)alate 
Cystic  sarcoma 
Cysts  of  antrum    . 


of  teeth 
dentigerous 
in  lower  jaw 
multilocular  of  lower  jaw 


Defoemities  of  the  jaws 
Dentigerous  cysts 
Dentinal  tumours  . 


'ch's 


.  372 

.  375 

.  377 
400,  401 

.  409 

.  414 

.  420 


oper 


.  48 

.  333 

ation.  404 

.  217 

,  114 

.  211 

.  298 


.  300 

.  307 

.  372 
72,80 

.  293 

.  43 

.  108 

.  268 

.  334 

.  152 

.  429 

.  113 

.  80 

.  300 

.  361 

.  388 

.  296 

.  376 

.  276 

.  15 
12,19 

.  93 

.  42 

.  91 

.  303 

.  359 

.  251 

.  202 

.  171 

.  178 

.  183 

.  181 

.  196 


428 
183 
217 


INDEX. 


475 


Diagnosis  of  tumours  of  upper  jaw 

„  „  lower  jaw 

Dislocation  of  teeth       ... 

„  with  fracture       .... 

„  of  jaw         ..... 

„  „     symptoms  of 

„  „     old  standing 

„  „     rare  forms 

J,  „     congenital 

„  „     treatment  of      . 

Dropsy  of  antrum  ..... 

Duka,  Dr.,  case  of  ivory  tumour  of  upper  jaw 

Enchondroma  of  upper  jaw 
„  lower  jaw 

Epithelioma  of  gums     . 
„        of  antrum 
Epulis    .... 

myeloid 

giant-celled  . 

epitheliomatous    . 

table  of  cases  of  .   . 

treatment  of 
Esmarch,  Professor,  on  closure  of  jaws 
Extraction  of  teeth  causing  fracture 

Falling  in  of  antrum    . 
False  joint  after  fracture 
J,         treatment  of 
Fearn,  Mr.,  dentigerous  cyst 
Fergusson,  Sir  W.,  case  of  hyperostosis  _ 
„  case  of  hydrops  antri 

„  cysts  in  lower  jaw  . 

„  odontoma 

„  epithelioma     . 

„  ivory  tumour  of  upper  jaw 

„  myeloid  tumour  of  lower  jaw 

Fibrous  tumours  of  upper  jaw 
„  lower  jaw 

Forceps,  Fergusson's     . 
„        Liston's  . 
„         Stromeyer's    . 
Forget,  Dr.,  on  dentigerous  cysts 

„  on  odontoma 

Four- tailed  bandage 
Fracture  of  lower  jaw   . 

,,  „  museum  specimens  of 

„  „  symptoms  of 

„  ramus  of  lower  jaw  . 

„  neck  of  condyle  of  lower  jaw 

„  coronoid  process 

„  of  lower  jaw,  complications  of 

„  teeth         .... 


PAGE 

314 

379 

16 

22 

83 
88 
90 
92 
93 
93 
168 
284 

268 
334 
254 
257 
235 
236 
237 
237 
239 
244 
393 
2 

177 

25 

53 

188 

146 

170 

183 

217 

255 

280 

359 

261 

327 

246 

245 

95 

189 

218 

33 

1 

4 

8 

11 

12 

14 

15 

16 


476 


INDEX. 


Fracture  of  alveolus 

„  of  glenoid  cavity 

„  of  lower  jaw,  treatment  of 

„  of  upper  jaw     .... 

„  complications  of         .         .         . 

Gexsoul  on  removal  of  upper  jaw 
Giraldes,  M.,  on  cysts  of  antrum  . 
Goodwillie,  Dr.,  on  temporo-maxillary  disease 
Graefe's  apparatus  for  fractured  upper  jaw 
Gross,  Dr.,  on  closure  of  jaws 
Growths  within  antrum 
Gums,  diseases  of  . 

,,      epithelioma  of     . 

„      hypertrophy  of    . 

,,      jDolypus  of . 

„      papilloma  of 
Gunning's  interdental  splints 
Gunshot  injuries  of  jaws 
Gutta-percha  splint 

„  wedges  for  fracture 

HjEMOEunAGE  after  fracture   . 
Hamilton's  sling  for  fracture. 
Hammond's  wire-splint 
Harrison,  Mr.,  odontoma 

,,  „     deformity  of  jaws  . 

Hart,  Mr.,  necrosis  of  upper  jaw  . 
Hay  ward,  Mr.,  cap  for  teeth . 
Hepburn,  Mr.,  case  of  angular  union 
Hill,  Mr.  B.,  modification  of  Lonsdale's  splint 
Hilton,  Mr.,  ivory  tumour  of  upper  jaw 
Holt,  Mr.,  recurrent  fibroid  of  lower  jaw 

,,         closure  of  jaws      .... 
Humphry,  Dr.,  prolapse  of  tongue,  producing  deformity  of 
Hydrops  antri        ... 
Hyperostosis  .... 

Hypertrophy  of  gums   . 

„  neck  and  condyle 

Inflammation 

Interdental  splint  (Gunning's) 

„  „  (Bean's)    . 

Irregular  union  after  fracture 

Ivory  tumour  of  upjDcr  jaw  . 

,,  ,,  lower  jaw    . 

Jaws,  gunshot  injuries  of 

infiammation  of  . 

abscess  of    . 

l^eriostitis  of 

caries  of   .    .    . 

necrosis  of  . 


jaw 


17 
19 
33 
66 
61 

316 

171 

421 

64 

391 

174 

227 

254 

227 

232 

234 

44 

66 

34 

42 

15,62 

35 

36 

220 

431 

117 

43 

21 

51 

279 

352 

406 

428 

168 

142 

227 

418 

98 
44 
48 
24 
279 
340 

66 

98 

99 

106 

108 

110 


INDEX. 


477 


Jaws,  necrosis 

of,  exanthematous 

. 

.     114 

,,             „             syphilitic    .... 

.     120 

„             „            pliosphorus        .         .         .         . 

.    122 

„       deformities  of 

.    428 

Jaw,  upper,  fractures  of 

.      66 

„                ,,               treatment  of     . 

.      62 

„            tumours  of           .         .         .         .         . 

.    260 

„                 ,,                fibrous      .         .         .         . 

.    261 

" 

,                cartilaginous    . 
,               osseous    .         .         .         . 
,               spindle-cell  sarcoma 
,                recurrent  fibroid 

.    268 

.  277 
.  287 
.    290 

" 

,                myeloid  sarcoma 

,                vascular  .         .         .         . 

,                chondro-sarcoma 

,                ossifying  sarcoma     . 

.  292 
.  297 
.  300 
.    300 

,                round-celled  sarcoma 
,               epithelioma 

.  302 
.    307 

,                diagnosis  of 

.    314 

ji 

„                prognosis  of 

.    315 

„               operations  on 

.    315 

Jaw,  lower,  fractures  of 

1 

„                  „             treatment  of 

.      33 

„                  „             suture  of . 

.      39 

„            dislocation  of 

.      83 

,,            cysts  in        .         .         . 

.    181 

„            tumours  of  . 

.    327 

„                   „              fibrous 

.    327 

,,                   „              cartilaginous 

.    334 

„                   „              osseous     . 

.     340 

„                  „             spiudle-celled  s 

arcoma 

.     344 

„                   „              recurrent  fibroid 

.     352 

,,                   ,,              myeloid  sarcoma 

.     357 

„                   „              cHondro-sarcoma     . 

.    361 

„                   „              ossifying  sarcoma    . 

.    364 

„                   „             round-celled  sarcoma 

.    369 

„                   „              epithelioma 

.    372 

„                  „             diagnosis  of 

.    379 

„           operations  on      ...        . 

.    380 

Lawson,  Mr.,  recurrent  fibroid  of  upper  jaw 

.    291 

,,                    ,,              ,,            lower  jaw. 

.    354 

„                    „          enchondroma  of  lower  ja-\ 

T 

.    337 

Ligature  of  teeth. 

.      35 

Liston,  Mr.,  case  of  large  epulis     . 

.     242 

„           fibrous  tumours  of  upper  jaw    . 

.     262 

Lonsdale's  splint 

.      50 

Lower  iaw,  fracture  of  . 

1 

„          dis 

location  of 

,         , 

.      83 

,,  tumours  of  (see  Tumours) 

MacGillivkay,  Mr.,  hypertrophy  of  gum 
Maisonneuve  on  dislocation  , 


229 

85 


478 


INDEX. 


Margetson,  Mr.,  case  of  fracture  and  dislocation  of  tootb    .        .  17 

Medullary  tumour  of  upper  jaw 302 

„              „             lower  jaw 369 

Moon,  Mr.,  splint  for  fi-acture        .......  52 

Multilocular  cysts  of  lower  jaw     .......  196 

„            cystic  tumour 205 

Myeloid  epulis 236 

,,      sarcoma  of  upper  jaw       .......  292 

„             ,,             lower  jaw 357 

Neck  of  condyle  fractured 12,19 

Necrosis  of  jaw 110 

exanthematous       ........  114 

syphilitic 120 

phosphorus 122 

symptoms  of ........         .  124 

rejiair  after     .........  127 

treatment  of  .         ........  137 

after  fracture         ........  20 

„               of  symphysis    ......  22 

Nelaton,  on  dislocation. 86,  95 

Neuralgia  after  fracture 17,  62 

Nicholson,  Mr.,  necrosis  of  alveolus 112 

Non-union  of  fracture  .         .         .         .   "     .         .         .         .25 

Odontomata 217 

Old-standing  dislocations 90 

Operations  on  upper  jaw 315 

„                lower  jaw 380 

Ossifying  sarcoma 300,  364 

Osteoma  of  upper  jaw 277 

„           lower  jaw 340 

Paget,  Sir  J.,  polypus  of  antrum  .         .                  ....  175 

Palate,  tumours  of  the  . .  248 

Paralysis  of  dental  nerve       .         .         .         .         .         .         .         17,  62 

Periostitis  of  jaw            . 106 

Permanent  closure  of  jaws 390 

Phosphorus-necrosis       .........  122 

Polypus  of  antrum .         .         .174 

Ramus  of  lower  jaw  fractured        .......  11 

Recurring-fibroid  of  upj^er  jaw 290 

„              „           lower  jaw       .                  352 

Repair  after  necrosis     .........  127 

Rheumatoid  arthritis,  temporo-maxillary     .....  415 

Rizzoli,  on  closure  of  jaws 397 

Salivary  fistula  after  fracture 20 

Salter,  Mr.,  case  of  fractured  upper  jaw         .                  ...  56 

„            on  exanthematous  necrosis          .....  114 

„            on  dentigerous  cysts  .......  185 

„           on  odontomata ,  223 


INDEX. 


479 


Salter,  Mr.,  on  hypertrophy  of  gum     . 

„  on  papilloma  of  gum 

Savory,  Mr.,  on  repair  after  phosphorus-necrosis 
Shillito,  Mr.  B.,  fibrous  tumour  of  lower  jaw 
Smith,  Mr.  Cox,  case  of  gunshot  injury  of  upper  j 
„  „  case  of  injury  to  symphysis 

„         Prof.  R.  W.,  on  dislocation 
,,         Mr.  T.,  on  phosphorus-necrosis 
Spasmodic  closure  of  jaws     . 
Specimens  of  fractured  jaw 
Splint,  interdental  (Gunning's)     . 

„  ,,  (Bean's) 

„      Lonsdale's 

„  „  Hill's  modification 

„      for  lower  jaw     . 
Square,  Mr.,  enchondroma  of  upper  jaw 
Stromeyer's  forceps 
Sub-luxation  of  jaw 
Sub-periosteal  resection 
SupiDuration  in  antrum 
Suture  of  lower  jaw 
Syme,  Mr.,  tumour  of  hard  palate 

„        „     osteo-sarcoma  of  lower  jaw 
Symphysis,  necrosis  of 
Symptoms  of  fractured  j  aw 
Syphilitic  necrosis 

Tay,  Mr,  W.,  necrosis  of  lower  jaw 
Teeth,  fracture  of         .         .         . 

„         dislocation  of    . 

„        ligature  of         .         .         . 

,,         tumours  connected  with    . 
Temporo-maxillary  articulation,  diseases  of 
Thomas's  wire-suture    . 
Tomes,  Mr.,  on  hypertrophy  of  gums 

„  „         dentigerous  cysts . 

„  „         odontomata 

Treatment  of  fractures  of  lower  jaw 
„  „         _      upper  jaw 

Tumours  connected  with  teeth 

„  papillary,  of  gum  . 

„  of  palate 

„  of  upper  jaw. 

„  „  fibrons 

„  „  cartilaginous 

„  „  osseous 

J,  „  spindle-celled  sarcoma 

„  „  recurrent-fibroid 

„  „  myeloid      . 

,,  „  vascular 

,,  „  malignant . 

J,  „  diagnosis  of 

„  treatment  of 


217,  222, 


PASB 

227 

234 

128 

330 

70 

11 

89 

130 

388 

4 

44 

48 

60 

51 

34 

275 

95 

415 

139 

159 

38 

248 

3i8 

22 

8 

120 

115 

16 

16 

35 

214 

412 

39 

231 

186 

225 

33 

62 

214 

234 

248 

260 

261 

268 

277 

287 

290 

292 

297 

302 

314 

315 


480 


INDEX. 


Tumours  of  lower  jaw 


cystic-sarcomatous 
fibrous 
cartilaginous 
osseoias 
spindle-celled  sarcoma 
recurrent-fibroid, 
myeloid 
malignant . 
diagnosis  of 
treatment  of 


UxiON  of  fracture  after  necrosis    . 

„       irregular,  of  fractured  lower  jaw 
United  States'  Army  Museum,  specimens  of  gunshot 
Ununited  fracture  of  lower  jaw     . 

„  ,,  treatment  of 

Upper  jaw,  fractures  of         .        .        . 
„  tumours  of  {see  Tumours) 


Vascular  tumours  of  upper  jaw 
Vasey,  Mr.,  deformity  of  jaw 
Vemeuil,  M.,  on  closure  of  jaws 


injury  in 


Warren,  Dr.  Mason,  on  cysts  of  lower 
Weiss,  Mr.  F.,  closure  by  cicatrix 
Wells,  Sir  S.,  fibrous  tumour  of  lower 
Wheelhouse's  method  of  wiring  jaw 
Wilkes,  Mr.,  epithelioma  of  lower  jaw 
Wire  si^lint,  Hammond's 
Wiring  lower  jaw 
Wounds  of  the  face 


jaw 
.]aw 


Appendix  of  Cases 


PAGE 

327 
202 
327 
334 
340 
344 
352 
357 
369 
379 
380 

21 

24 
76 
25 
63 
66 


297 
430 
400 

211 

405 
328 
40 
376 
36 
39 
15 


434 


THE  END. 


HALLANTYNB    PRESS,    CHANPOS   STREET,   W.C. 


-^y 


RD526 


/J 


H35 
1884 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  526  H35  1884  C.1 

Iniuries  and  diseases  of  the  jaws 


2002242915 


